Provider Demographics
NPI:1811900749
Name:SPACE COAST ORTHOPAEDIC CENTER PL
Entity type:Organization
Organization Name:SPACE COAST ORTHOPAEDIC CENTER PL
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PARTNER
Authorized Official - Prefix:DR
Authorized Official - First Name:HANI
Authorized Official - Middle Name:H
Authorized Official - Last Name:EL KOMMOS
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:321-459-1446
Mailing Address - Street 1:220 N SYKES CREEK PKWY
Mailing Address - Street 2:SUITE 200
Mailing Address - City:MERRITT ISLAND
Mailing Address - State:FL
Mailing Address - Zip Code:32953-3490
Mailing Address - Country:US
Mailing Address - Phone:321-459-1446
Mailing Address - Fax:321-456-5195
Practice Address - Street 1:220 N SYKES CREEK PKWY
Practice Address - Street 2:SUITE 200
Practice Address - City:MERRITT ISLAND
Practice Address - State:FL
Practice Address - Zip Code:32953-3490
Practice Address - Country:US
Practice Address - Phone:321-459-1446
Practice Address - Fax:321-456-5195
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-14
Last Update Date:2014-01-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL265066500Medicaid
FL265066500Medicaid