Provider Demographics
NPI:1194303487
Name:INSTITUTE OF REGENERATIVE ORTHOPEDICS AND SPORTS MEDICINE LLC
Entity type:Organization
Organization Name:INSTITUTE OF REGENERATIVE ORTHOPEDICS AND SPORTS MEDICINE LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:JORGE
Authorized Official - Middle Name:ANTONIO
Authorized Official - Last Name:GONZALEZ
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:786-566-0338
Mailing Address - Street 1:1441 NE 54TH ST
Mailing Address - Street 2:
Mailing Address - City:FORT LAUDERDALE
Mailing Address - State:FL
Mailing Address - Zip Code:33334-4932
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:3333 W COMMERCIAL BLVD STE 101
Practice Address - Street 2:
Practice Address - City:FORT LAUDERDALE
Practice Address - State:FL
Practice Address - Zip Code:33309-3424
Practice Address - Country:US
Practice Address - Phone:786-566-0338
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-03-30
Last Update Date:2022-02-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RS0010XAllopathic & Osteopathic PhysiciansInternal MedicineSports MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL017619600Medicaid