Basic Information
| Provider Information | |||||||||
| NPI: | 1477296952 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | FLORIDA TRAUMA SERVICES, LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 748538 | ||||||||
| Address2: | |||||||||
| City: | ATLANTA | ||||||||
| State: | GA | ||||||||
| PostalCode: | 303748538 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6153737600 | ||||||||
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| Practice Location | |||||||||
| Address1: | 1703 LEWIS TURNER BLVD | ||||||||
| Address2: | |||||||||
| City: | FORT WALTON BEACH | ||||||||
| State: | FL | ||||||||
| PostalCode: | 325471221 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8508644033 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 04/14/2022 | ||||||||
| LastUpdateDate: | 04/14/2022 | ||||||||
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| AuthorizedOfficialLastName: | JOHNSON | ||||||||
| AuthorizedOfficialFirstName: | WILLIAM | ||||||||
| AuthorizedOfficialMiddleName: | TEDERICK | ||||||||
| AuthorizedOfficialTitleorPosition: | GROUP VICE PRESIDENT/AO | ||||||||
| AuthorizedOfficialTelephone: | 6153737630 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| NPICertificationDate: | 04/14/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208600000X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Surgery | 2086S0127X | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Surgery | Trauma Surgery |
No ID Information.