Provider Demographics
NPI:1952750713
Name:PROVIDENT ORTHOPEDIC AND SPORTS MEDICINE CENTER
Entity Type:Organization
Organization Name:PROVIDENT ORTHOPEDIC AND SPORTS MEDICINE CENTER
Other - Org Name:PROVIDENT
Other - Org Type:Other Name
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:PAUL
Authorized Official - Middle Name:F
Authorized Official - Last Name:SHULER
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:920-344-8665
Mailing Address - Street 1:801 MARSHALL FARMS RD
Mailing Address - Street 2:
Mailing Address - City:OCOEE
Mailing Address - State:FL
Mailing Address - Zip Code:34761-3316
Mailing Address - Country:US
Mailing Address - Phone:407-906-3621
Mailing Address - Fax:
Practice Address - Street 1:801 MARSHALL FARMS RD
Practice Address - Street 2:
Practice Address - City:OCOEE
Practice Address - State:FL
Practice Address - Zip Code:34761-3316
Practice Address - Country:US
Practice Address - Phone:407-906-3621
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-06-11
Last Update Date:2021-05-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic SurgeryGroup - Single Specialty