Provider Demographics
NPI:1912932047
Name:ORTHOPEDIC CENTER OF FLORIDA, INC
Entity Type:Organization
Organization Name:ORTHOPEDIC CENTER OF FLORIDA, INC
Other - Org Name:SPORTS MEDICINE AND JOINT REPLACEMENT SPECIALIST
Other - Org Type:Former Legal Business Name
Authorized Official - Title/Position:VP
Authorized Official - Prefix:MR
Authorized Official - First Name:MARK
Authorized Official - Middle Name:
Authorized Official - Last Name:FARMER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:239-482-2663
Mailing Address - Street 1:12670 CREEKSIDE LANE
Mailing Address - Street 2:SUITE 202
Mailing Address - City:FORT MYERS
Mailing Address - State:FL
Mailing Address - Zip Code:33919-8759
Mailing Address - Country:US
Mailing Address - Phone:239-482-2663
Mailing Address - Fax:239-482-7585
Practice Address - Street 1:12670 CREEKSIDE LANE
Practice Address - Street 2:SUITE 202
Practice Address - City:FORT MYERS
Practice Address - State:FL
Practice Address - Zip Code:33919-8759
Practice Address - Country:US
Practice Address - Phone:239-482-2663
Practice Address - Fax:239-482-7585
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-11
Last Update Date:2022-12-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLK0865OtherMEDICARE GROUP
FL00231OtherGROUP BCBS OF FLORIDA
FL265840200Medicaid
FL0670070001OtherMEDICARE DME
FL265840200Medicaid
FL0670070001Medicare NSC
FL=========OtherTAX IDENTIFICATION