Provider Demographics
NPI:1104819499
Name:PENSACOLA BONE & JOINT CLINIC PA
Entity type:Organization
Organization Name:PENSACOLA BONE & JOINT CLINIC PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:THEODORE
Authorized Official - Last Name:DEJONG
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:850-479-7229
Mailing Address - Street 1:5147 N 9TH AVE
Mailing Address - Street 2:SUITE 110
Mailing Address - City:PENSACOLA
Mailing Address - State:FL
Mailing Address - Zip Code:32504-8771
Mailing Address - Country:US
Mailing Address - Phone:850-479-7229
Mailing Address - Fax:850-479-7250
Practice Address - Street 1:5147 N 9TH AVE
Practice Address - Street 2:SUITE 110
Practice Address - City:PENSACOLA
Practice Address - State:FL
Practice Address - Zip Code:32504-8771
Practice Address - Country:US
Practice Address - Phone:850-479-7229
Practice Address - Fax:850-479-7250
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-08-23
Last Update Date:2009-08-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXL1829207X00000X
FLME0053867207X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic SurgeryGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL251235100Medicaid
AL009920660Medicaid
FL32487OtherBCBS
AL009920660Medicaid
G40603Medicare UPIN