Provider Demographics
NPI:1588843981
Name:CORDOVA ORTHOPAEDIC ASSOCIATES PA
Entity Type:Organization
Organization Name:CORDOVA ORTHOPAEDIC ASSOCIATES PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:DOUGLAS
Authorized Official - Middle Name:
Authorized Official - Last Name:TAPPAN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:850-474-1925
Mailing Address - Street 1:5120 BAYOU BLVD
Mailing Address - Street 2:SUITE 2
Mailing Address - City:PENSACOLA
Mailing Address - State:FL
Mailing Address - Zip Code:32503-2135
Mailing Address - Country:US
Mailing Address - Phone:850-474-1925
Mailing Address - Fax:850-479-7595
Practice Address - Street 1:5120 BAYOU BLVD
Practice Address - Street 2:SUITE 2
Practice Address - City:PENSACOLA
Practice Address - State:FL
Practice Address - Zip Code:32503-2135
Practice Address - Country:US
Practice Address - Phone:850-474-1925
Practice Address - Fax:850-479-7595
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:CORDOVA ORTHOPAEDIC ASSOCIATES PA
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2007-11-01
Last Update Date:2012-11-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME42814174400000X
FLME00042814174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL068249700Medicaid
FL068249700Medicaid
FLKOO11Medicare PIN
FL57093ZMedicare PIN
FL0603760001Medicare NSC
FLD56809Medicare UPIN