Provider Demographics
NPI:1831137066
Name:ORTHOSPORTS LLC
Entity Type:Organization
Organization Name:ORTHOSPORTS LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ORTHPEDIC SURGEON
Authorized Official - Prefix:MS
Authorized Official - First Name:BRIAN
Authorized Official - Middle Name:C
Authorized Official - Last Name:OLIVER
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:727-725-6231
Mailing Address - Street 1:3251 MCMULLEN BOOTH ROAD
Mailing Address - Street 2:SUITE 201
Mailing Address - City:CLEARWATER
Mailing Address - State:FL
Mailing Address - Zip Code:33761
Mailing Address - Country:US
Mailing Address - Phone:727-725-6231
Mailing Address - Fax:727-791-4563
Practice Address - Street 1:3251 MCMULLEN BOOTH ROAD
Practice Address - Street 2:SUITE 201
Practice Address - City:CLEARWATER
Practice Address - State:FL
Practice Address - Zip Code:33761
Practice Address - Country:US
Practice Address - Phone:727-725-6231
Practice Address - Fax:727-791-4563
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-02
Last Update Date:2008-11-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL051214100Medicaid
FL10411OtherBLUE SHIELD
FL219099OtherAVMED
FL7731133OtherAETNA PPO/MC PIN
FL2374595OtherAETNA HMO PVN
FL1688827008OtherCIGNA
FLK9604Medicare PIN
FL219099OtherAVMED
FL5852450001Medicare NSC