Provider Demographics
NPI:1386160513
Name:ORTHONORTHRUP PA
Entity type:Organization
Organization Name:ORTHONORTHRUP PA
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:MEDICAL DIRECTOR, OWNER
Authorized Official - Prefix:
Authorized Official - First Name:TOD
Authorized Official - Middle Name:
Authorized Official - Last Name:NORTHRUP
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:904-466-1197
Mailing Address - Street 1:PO BOX 4389
Mailing Address - Street 2:
Mailing Address - City:ST AUGUSTINE
Mailing Address - State:FL
Mailing Address - Zip Code:32085-4389
Mailing Address - Country:US
Mailing Address - Phone:904-466-1197
Mailing Address - Fax:904-823-8967
Practice Address - Street 1:475 W TOWN PL STE 106
Practice Address - Street 2:
Practice Address - City:ST AUGUSTINE
Practice Address - State:FL
Practice Address - Zip Code:32092-2820
Practice Address - Country:US
Practice Address - Phone:904-466-1179
Practice Address - Fax:904-823-8967
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-08-18
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLOS7217207XX0005X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207XX0005XAllopathic & Osteopathic PhysiciansOrthopaedic SurgerySports MedicineGroup - Single Specialty