Provider Demographics
NPI:1932479938
Name:ORLANDO PHYSICIAN SPECIALISTS, LLC
Entity Type:Organization
Organization Name:ORLANDO PHYSICIAN SPECIALISTS, LLC
Other - Org Name:UROLOGY CONSULTANTS
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:ELIAS
Authorized Official - Middle Name:
Authorized Official - Last Name:JACOBO
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:407-332-0777
Mailing Address - Street 1:PO BOX 11984
Mailing Address - Street 2:MSC 315
Mailing Address - City:BIRMINGHAM
Mailing Address - State:AL
Mailing Address - Zip Code:35202-1984
Mailing Address - Country:US
Mailing Address - Phone:407-478-4920
Mailing Address - Fax:904-345-5841
Practice Address - Street 1:1561 W. FAIRBANKS AVE
Practice Address - Street 2:
Practice Address - City:WINTER PARK
Practice Address - State:FL
Practice Address - Zip Code:32789
Practice Address - Country:US
Practice Address - Phone:407-478-4920
Practice Address - Fax:407-332-8767
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-01-06
Last Update Date:2014-11-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261QR0200XAmbulatory Health Care FacilitiesClinic/CenterRadiology
No208800000XAllopathic & Osteopathic PhysiciansUrologyGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL0027JOtherBCBS
FG093AMedicare PIN
FLFG093AMedicare PIN
FG093BMedicare PIN