Provider Demographics
NPI:1881792216
Name:SPECIALTY ORTHOPEDIC ASSOCIATES PL
Entity type:Organization
Organization Name:SPECIALTY ORTHOPEDIC ASSOCIATES PL
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:PONNAVOLU
Authorized Official - Middle Name:D
Authorized Official - Last Name:REDDY
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:863-676-9523
Mailing Address - Street 1:PO BOX 552187
Mailing Address - Street 2:
Mailing Address - City:TAMPA
Mailing Address - State:FL
Mailing Address - Zip Code:33655-0001
Mailing Address - Country:US
Mailing Address - Phone:863-676-9523
Mailing Address - Fax:863-678-3043
Practice Address - Street 1:1204 CARLTON AVENUE
Practice Address - Street 2:
Practice Address - City:LAKE WALES
Practice Address - State:FL
Practice Address - Zip Code:33853
Practice Address - Country:US
Practice Address - Phone:863-676-9523
Practice Address - Fax:863-678-3043
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-20
Last Update Date:2008-07-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME85679207X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
DE2688OtherRAILROAD MEDICARE
FLK8259Medicare ID - Type UnspecifiedMEDICARE GROUP #
FL5842690001Medicare NSC
DE2688OtherRAILROAD MEDICARE