Provider Demographics
NPI:1487649935
Name:ORTHO FLORIDA LLC
Entity Type:Organization
Organization Name:ORTHO FLORIDA LLC
Other - Org Name:FT LAUDERDALE ORTHO AND SPORTS MEDICINE, LLC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:MR
Authorized Official - First Name:DANE
Authorized Official - Middle Name:
Authorized Official - Last Name:TRASK
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:813-787-1128
Mailing Address - Street 1:1414 SE 3RD AVE
Mailing Address - Street 2:
Mailing Address - City:FORT LAUDERDALE
Mailing Address - State:FL
Mailing Address - Zip Code:33316-1910
Mailing Address - Country:US
Mailing Address - Phone:954-764-8033
Mailing Address - Fax:954-764-5522
Practice Address - Street 1:1414 SE 3RD AVE
Practice Address - Street 2:
Practice Address - City:FORT LAUDERDALE
Practice Address - State:FL
Practice Address - Zip Code:33316-1910
Practice Address - Country:US
Practice Address - Phone:954-764-8033
Practice Address - Fax:954-764-5522
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-09-12
Last Update Date:2016-01-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL207X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic SurgeryGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL375852400Medicaid
FLCN7775OtherRAILROAD MEDICARE
CD864AMedicare PIN
FL6142960008Medicare NSC
FLCN7775OtherRAILROAD MEDICARE
FLCN7775OtherRAILROAD MEDICARE