Provider Demographics
NPI: | 1821097437 |
---|---|
Name: | JEWETT ORTHOPAEDIC CLINIC LLC |
Entity Type: | Organization |
Organization Name: | JEWETT ORTHOPAEDIC CLINIC LLC |
Other - Org Name: | |
Other - Org Type: | |
Authorized Official - Title/Position: | C.E.O. |
Authorized Official - Prefix: | DR |
Authorized Official - First Name: | MICHAEL |
Authorized Official - Middle Name: | V |
Authorized Official - Last Name: | JABLONSKI |
Authorized Official - Suffix: | |
Authorized Official - Credentials: | MD |
Authorized Official - Phone: | 407-647-2287 |
Mailing Address - Street 1: | 1285 ORANGE AVE |
Mailing Address - Street 2: | |
Mailing Address - City: | WINTER PARK |
Mailing Address - State: | FL |
Mailing Address - Zip Code: | 32789-4949 |
Mailing Address - Country: | US |
Mailing Address - Phone: | 407-647-2287 |
Mailing Address - Fax: | 407-643-1300 |
Practice Address - Street 1: | 1285 ORANGE AVE |
Practice Address - Street 2: | |
Practice Address - City: | WINTER PARK |
Practice Address - State: | FL |
Practice Address - Zip Code: | 32789-4949 |
Practice Address - Country: | US |
Practice Address - Phone: | 407-647-2287 |
Practice Address - Fax: | 407-643-1300 |
EIN: | <UNAVAIL> |
Is Organization Subpart?: | No |
Parent Organization LBN: | |
Parent Organization TIN: | |
Enumeration Date: | 2005-07-15 |
Last Update Date: | 2015-01-14 |
Deactivation Date: | |
Deactivation Code: | |
Reactivation Date: |
Provider Licenses
State | License ID | Taxonomies |
---|---|---|
FL | 207X00000X, 207XS0106X, 207XS0114X, 207XS0117X, 207XX0004X, 207XX0005X, 207XX0801X, 208100000X, 2085B0100X, 2085N0700X, 2085R0202X, 2471B0102X, 332B00000X, 335E00000X |
Provider Taxonomies
Primary? | Code | Type | Classification | Specialization | Group |
---|---|---|---|---|---|
Yes | 207X00000X | Allopathic & Osteopathic Physicians | Orthopaedic Surgery | Group - Multi-Specialty | |
No | 207XS0106X | Allopathic & Osteopathic Physicians | Orthopaedic Surgery | Hand Surgery | Group - Multi-Specialty |
No | 207XS0114X | Allopathic & Osteopathic Physicians | Orthopaedic Surgery | Adult Reconstructive Orthopaedic Surgery | Group - Multi-Specialty |
No | 207XS0117X | Allopathic & Osteopathic Physicians | Orthopaedic Surgery | Orthopaedic Surgery of the Spine | Group - Multi-Specialty |
No | 207XX0004X | Allopathic & Osteopathic Physicians | Orthopaedic Surgery | Foot and Ankle Surgery | Group - Multi-Specialty |
No | 207XX0005X | Allopathic & Osteopathic Physicians | Orthopaedic Surgery | Sports Medicine | Group - Multi-Specialty |
No | 207XX0801X | Allopathic & Osteopathic Physicians | Orthopaedic Surgery | Orthopaedic Trauma | Group - Multi-Specialty |
No | 208100000X | Allopathic & Osteopathic Physicians | Physical Medicine & Rehabilitation | Group - Multi-Specialty | |
No | 2085B0100X | Allopathic & Osteopathic Physicians | Radiology | Body Imaging | Group - Multi-Specialty |
No | 2085N0700X | Allopathic & Osteopathic Physicians | Radiology | Neuroradiology | Group - Multi-Specialty |
No | 2085R0202X | Allopathic & Osteopathic Physicians | Radiology | Diagnostic Radiology | Group - Multi-Specialty |
No | 2471B0102X | Technologists, Technicians & Other Technical Service Providers | Radiologic Technologist | Bone Densitometry | Group - Multi-Specialty |
No | 332B00000X | Suppliers | Durable Medical Equipment & Medical Supplies | Group - Multi-Specialty | |
No | 335E00000X | Suppliers | Prosthetic/Orthotic Supplier | Group - Multi-Specialty |
Provider Identifiers
State | Identifier ID | ID Type | Issuer |
---|---|---|---|
FL | 060759200 | Medicaid | |
FL | 0465930003 | Medicare NSC | |
FL | 99239 | Medicare PIN | |
FL | 0465930003 | Medicare NSC |