Provider Demographics
NPI:1962574541
Name:BOLLETTIERI SPORTS MEDICINE CENTER
Entity type:Organization
Organization Name:BOLLETTIERI SPORTS MEDICINE CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGING PARTNER
Authorized Official - Prefix:
Authorized Official - First Name:JAY
Authorized Official - Middle Name:S
Authorized Official - Last Name:FRYE
Authorized Official - Suffix:
Authorized Official - Credentials:PT
Authorized Official - Phone:941-755-0068
Mailing Address - Street 1:5500 34TH STREET WEST
Mailing Address - Street 2:
Mailing Address - City:BRADENTON
Mailing Address - State:FL
Mailing Address - Zip Code:34210-3506
Mailing Address - Country:US
Mailing Address - Phone:941-755-0068
Mailing Address - Fax:941-727-7502
Practice Address - Street 1:5500 34TH STREET WEST
Practice Address - Street 2:
Practice Address - City:BRADENTON
Practice Address - State:FL
Practice Address - Zip Code:34210-3506
Practice Address - Country:US
Practice Address - Phone:941-755-0068
Practice Address - Fax:941-727-7502
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-15
Last Update Date:2012-02-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2000XAmbulatory Health Care FacilitiesClinic/CenterPhysical Therapy
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLQ3BOtherBLUE CROSS BLUE SHIELD FL
FL5864226-003OtherCIGNA HEALTHCARE
FLQ3BOtherBLUE CROSS BLUE SHIELD FL