Provider Demographics
NPI:1295769263
Name:BEACH ORTHOPAEDIC & SPORTS MEDICINE CLINIC, PA
Entity type:Organization
Organization Name:BEACH ORTHOPAEDIC & SPORTS MEDICINE CLINIC, PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT/OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:SAMUEL
Authorized Official - Middle Name:WILLIAM
Authorized Official - Last Name:CAPRA
Authorized Official - Suffix:JR
Authorized Official - Credentials:MD
Authorized Official - Phone:850-664-5633
Mailing Address - Street 1:1032 MAR WALT DR
Mailing Address - Street 2:SUITE 210
Mailing Address - City:FORT WALTON BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:32547-6645
Mailing Address - Country:US
Mailing Address - Phone:850-664-5633
Mailing Address - Fax:850-315-2664
Practice Address - Street 1:1032 MAR WALT DR
Practice Address - Street 2:SUITE 210
Practice Address - City:FORT WALTON BEACH
Practice Address - State:FL
Practice Address - Zip Code:32547-6645
Practice Address - Country:US
Practice Address - Phone:850-664-5633
Practice Address - Fax:850-315-2664
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-10
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME94278207X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic SurgeryGroup - Single Specialty