Provider Demographics
NPI:1700119443
Name:BLUEWATER ORTHOPEDICS, P.A.
Entity Type:Organization
Organization Name:BLUEWATER ORTHOPEDICS, P.A.
Other - Org Name:BLUEWATER ORTHOPEDICS AND REHABILITATION
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:THOMAS
Authorized Official - Middle Name:
Authorized Official - Last Name:FOX
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:850-897-8081
Mailing Address - Street 1:1950 BLUEWATER BLVD STE 100
Mailing Address - Street 2:
Mailing Address - City:NICEVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32578-3888
Mailing Address - Country:US
Mailing Address - Phone:850-897-8081
Mailing Address - Fax:850-897-1520
Practice Address - Street 1:120 E REDSTONE AVE
Practice Address - Street 2:SUITE B
Practice Address - City:CRESTVIEW
Practice Address - State:FL
Practice Address - Zip Code:32539-5370
Practice Address - Country:US
Practice Address - Phone:850-398-8600
Practice Address - Fax:850-897-1520
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-09-14
Last Update Date:2017-03-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL601421174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL250939303Medicaid
FL40238Medicare PIN
FL250939303Medicaid