Provider Demographics
NPI:1023129178
Name:ORLANDO SPORTS MEDICINE GROUP INC
Entity type:Organization
Organization Name:ORLANDO SPORTS MEDICINE GROUP INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:ERIC
Authorized Official - Middle Name:
Authorized Official - Last Name:GREENO
Authorized Official - Suffix:
Authorized Official - Credentials:PT
Authorized Official - Phone:407-207-7188
Mailing Address - Street 1:12780 WATERFORD LAKES PKWY
Mailing Address - Street 2:SUITE 115
Mailing Address - City:ORLANDO
Mailing Address - State:FL
Mailing Address - Zip Code:32828-4500
Mailing Address - Country:US
Mailing Address - Phone:407-207-7188
Mailing Address - Fax:407-207-7103
Practice Address - Street 1:12780 WATERFORD LAKES PKWY
Practice Address - Street 2:SUITE 115
Practice Address - City:ORLANDO
Practice Address - State:FL
Practice Address - Zip Code:32828-4500
Practice Address - Country:US
Practice Address - Phone:407-207-7188
Practice Address - Fax:407-207-7103
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-31
Last Update Date:2008-08-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM1300XAmbulatory Health Care FacilitiesClinic/CenterMulti-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLY902TOtherBLUE CROSS BLUE SHIELD
FLK8482Medicare ID - Type Unspecified