Provider Demographics
NPI:1417943846
Name:HIGHLAND CENTER FOR ORTHOPEDICS & UPPER EXTREMITY SURGERY P A
Entity Type:Organization
Organization Name:HIGHLAND CENTER FOR ORTHOPEDICS & UPPER EXTREMITY SURGERY P A
Other - Org Name:HIGHLAND CENTER FOR ORTHOPAEDICS
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:BRIAN
Authorized Official - Middle Name:MICHAEL
Authorized Official - Last Name:JURBALA
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:863-709-8777
Mailing Address - Street 1:2161 E COUNTY ROAD 540A
Mailing Address - Street 2:#286
Mailing Address - City:LAKELAND
Mailing Address - State:FL
Mailing Address - Zip Code:33813-3794
Mailing Address - Country:US
Mailing Address - Phone:863-398-0039
Mailing Address - Fax:863-709-1060
Practice Address - Street 1:3317 US HIGHWAY 98 S STE 9
Practice Address - Street 2:
Practice Address - City:LAKELAND
Practice Address - State:FL
Practice Address - Zip Code:33803-8316
Practice Address - Country:US
Practice Address - Phone:863-709-8777
Practice Address - Fax:863-709-1060
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-09-21
Last Update Date:2014-04-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME70116207XS0114X
FLME99610208100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207XS0114XAllopathic & Osteopathic PhysiciansOrthopaedic SurgeryAdult Reconstructive Orthopaedic SurgeryGroup - Multi-Specialty
No208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & RehabilitationGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL10D2004873OtherCLIA LICENSE 22411 HWY 27 LAKE WALES
FL10D2004874OtherCLIA LICENSE FOR 3317 US HWY 98 SOUTH STE 9
FL10D2004874OtherCLIA LICENSE FOR 3317 US HWY 98 SOUTH STE 9
FLK6322Medicare ID - Type UnspecifiedMEDICARE GROUP #
FL5377960004Medicare NSC
FL=========OtherTRICARE GROUP #
FL10D2004874OtherCLIA LICENSE FOR 3317 US HWY 98 SOUTH STE 9
FL5377960005Medicare NSC