Provider Demographics
NPI:1760979140
Name:ORTHOPAEDIC MEDICAL GROUP OF TAMPA BAY PA
Entity Type:Organization
Organization Name:ORTHOPAEDIC MEDICAL GROUP OF TAMPA BAY PA
Other - Org Name:ORTHOPAEDIC MEDICAL GROUP PHYSICAL THERAPY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CREDENTIALING
Authorized Official - Prefix:
Authorized Official - First Name:TARYN
Authorized Official - Middle Name:
Authorized Official - Last Name:REID
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:813-534-0102
Mailing Address - Street 1:615 VONDERBURG DR
Mailing Address - Street 2:
Mailing Address - City:BRANDON
Mailing Address - State:FL
Mailing Address - Zip Code:33511-5972
Mailing Address - Country:US
Mailing Address - Phone:813-684-2663
Mailing Address - Fax:
Practice Address - Street 1:10740 PALM RIVER RD STE 310
Practice Address - Street 2:
Practice Address - City:TAMPA
Practice Address - State:FL
Practice Address - Zip Code:33619-4577
Practice Address - Country:US
Practice Address - Phone:813-684-2663
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:ORTHOPAEDIC MEDICAL GROUP OF TAMPA BAY
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2018-04-20
Last Update Date:2019-07-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & RehabilitationGroup - Multi-Specialty
No207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic SurgeryGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL374193100Medicaid