Provider Demographics
NPI:1629061007
Name:TAMPA BAY ORTHOPAEDIC DESIGNS INC
Entity Type:Organization
Organization Name:TAMPA BAY ORTHOPAEDIC DESIGNS INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:OLAF
Authorized Official - Middle Name:MICKLE
Authorized Official - Last Name:HOLM
Authorized Official - Suffix:SR
Authorized Official - Credentials:LPO, CO, BOCPO
Authorized Official - Phone:813-224-0525
Mailing Address - Street 1:812 W MARTIN LUTHER KING BLVD
Mailing Address - Street 2:STE 100
Mailing Address - City:TAMPA
Mailing Address - State:FL
Mailing Address - Zip Code:33603-3338
Mailing Address - Country:US
Mailing Address - Phone:813-224-0525
Mailing Address - Fax:813-224-0622
Practice Address - Street 1:812 W MARTIN LUTHER KING BLVD
Practice Address - Street 2:STE 100
Practice Address - City:TAMPA
Practice Address - State:FL
Practice Address - Zip Code:33603-3338
Practice Address - Country:US
Practice Address - Phone:813-224-0525
Practice Address - Fax:813-224-0622
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-08-31
Last Update Date:2019-12-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPOR124335E00000X, 335E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes335E00000XSuppliersProsthetic/Orthotic Supplier
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL005843900Medicaid
FL005843900Medicaid