| Entity Name: | ORTHOPAEDIC MEDICAL GROUP OF TAMPA BAY PA |
| Jurisdiction: | FLORIDA |
| Filing Type: | Domestic Profit |
| Status: | Active |
| Date Filed: | 13 Jun 1978 (47 years ago) |
| Document Number: | 575577 |
| FEI/EIN Number | 591830246 |
| Address: | 13837 Circa Crossing Drive, Suite 140, Lithia, FL, 33547, US |
| Mail Address: | 13837 CIRCA CROSSING DR, LITHIA, FL, 33547, US |
| ZIP code: | 33547 |
| County: | Hillsborough |
| Place of Formation: | FLORIDA |
| NPI | Enumeration Date | Last Update Date | Mailing Address | Practice Location Address | |||||||||||||||||||||||||||||||||||
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| 1316646516 | 2023-02-27 | 2024-10-22 | PO BOX 850001 DEPT 8272, ORLANDO, FL, 328858272, US | 2553 WINDGUARD CIR, WESLEY CHAPEL, FL, 335447351, US | |||||||||||||||||||||||||||||||||||
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| Phone | +1 816-684-2663 |
| Fax | 8136586222 |
| Phone | +1 813-684-2663 |
Authorized person
| Name | SCOTT GOLDSMITH |
| Role | PRESIDENT |
| Phone | 8136842663 |
Taxonomy
| Taxonomy Code | 207T00000X - Neurological Surgery Physician |
| Is Primary | No |
| Taxonomy Code | 207X00000X - Orthopaedic Surgery Physician |
| Is Primary | Yes |
| Taxonomy Code | 208100000X - Physical Medicine & Rehabilitation Physician |
| Is Primary | No |
| Taxonomy Code | 213E00000X - Podiatrist |
| Is Primary | No |
Other Provider Identifiers
| Issuer | MEDICAID |
| Number | 122422100 |
| State | FL |
| Name | Role | Address |
|---|---|---|
| GOLDSMITH SCOTT EDr. | Agent | 13837 Circa Crossing Drive, LTHIA, FL, 33547 |
| Name | Role | Address |
|---|---|---|
| GOLDSMITH, SCOTT | President | 4931 San Rafael, TAMPA, FL, 33629 |
| Name | Role | Address |
|---|---|---|
| Becker Edward | Manager | 4642 W. Lamb, Tampa, FL, 33629 |
| Butler Robert BDr. | Manager | 1911 S. Ardsley Street, Tampa, FL, 33629 |
| Jester Adam | Manager | 5306 E. Longboat Blvd., Tampa, FL, 33615 |
| Sando Mark Dr. | Manager | 4906 W. Juno Street, Tampa, FL, 33629 |
| Donaldson Christopher | Manager | 3510 W. Vasconia Street, Tampa, FL, 33629 |
| Event Type | Filed Date | Value | Description |
|---|---|---|---|
| NAME CHANGE AMENDMENT | 2016-06-17 | ORTHOPAEDIC MEDICAL GROUP OF TAMPA BAY PA | No data |
| CANCEL ADM DISS/REV | 2009-10-07 | No data | No data |
| ADMIN DISSOLUTION FOR ANNUAL REPORT | 2009-09-25 | No data | No data |
| NAME CHANGE AMENDMENT | 1991-07-29 | ORTHOPEDIC MEDICAL GROUP OF TAMPA BAY, P.A. | No data |
| NAME CHANGE AMENDMENT | 1984-02-29 | FIELD & GOLDSMITH, M.D.'S, P.A. | No data |
Date of last update: 02 Jan 2025
Sources: Florida Department of State
