Provider Demographics
NPI:1073832812
Name:BOYETTE ORTHOPEDICS & SPORTS MEDICINE, PA
Entity type:Organization
Organization Name:BOYETTE ORTHOPEDICS & SPORTS MEDICINE, PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR OF REVENUE CYCLE
Authorized Official - Prefix:
Authorized Official - First Name:MARY
Authorized Official - Middle Name:
Authorized Official - Last Name:HALTIGAN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:877-856-3774
Mailing Address - Street 1:2675 WINKLER AVE FL 2
Mailing Address - Street 2:
Mailing Address - City:FORT MYERS
Mailing Address - State:FL
Mailing Address - Zip Code:33901-9342
Mailing Address - Country:US
Mailing Address - Phone:877-856-3774
Mailing Address - Fax:395-992-6122
Practice Address - Street 1:4205 BEN FRANKLIN BLVD
Practice Address - Street 2:
Practice Address - City:DURHAM
Practice Address - State:NC
Practice Address - Zip Code:27704-2143
Practice Address - Country:US
Practice Address - Phone:919-477-6900
Practice Address - Fax:919-620-0974
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-05-19
Last Update Date:2024-06-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
207R00000X
NC9400729207X00000X, 332B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
No207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic SurgeryGroup - Single Specialty
No332B00000XSuppliersDurable Medical Equipment & Medical SuppliesGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC6528310001Medicare NSC