| Entity Name: | BLUEWATER ORTHOPEDICS, P.A. |
| Jurisdiction: | FLORIDA |
| Filing Type: | Domestic Profit |
| Status: | Active |
| Date Filed: | 09 Feb 1994 (31 years ago) |
| Document Number: | P94000010759 |
| FEI/EIN Number | 593228032 |
| Address: | 1950 BLUEWATER BLVD, SUITE 100, NICEVILLE, FL, 32578 |
| Mail Address: | 1950 BLUEWATER BLVD, SUITE 100, NICEVILLE, FL, 32578 |
| ZIP code: | 32578 |
| County: | Okaloosa |
| Place of Formation: | FLORIDA |
| NPI | Enumeration Date | Last Update Date | Mailing Address | Practice Location Address | |||||||||||||||||||||||||||
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| 1700119443 | 2009-09-14 | 2017-03-02 | 1950 BLUEWATER BLVD STE 100, NICEVILLE, FL, 325783888, US | 120 E REDSTONE AVE, SUITE B, CRESTVIEW, FL, 325395370, US | |||||||||||||||||||||||||||
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| Phone | +1 850-897-8081 |
| Fax | 8508971520 |
| Phone | +1 850-398-8600 |
Authorized person
| Name | MR. THOMAS FOX |
| Role | PRESIDENT |
| Phone | 8508978081 |
Taxonomy
| Taxonomy Code | 174400000X - Specialist |
| License Number | 601421 |
| State | FL |
| Is Primary | Yes |
Other Provider Identifiers
| Issuer | MEDICAID |
| Number | 250939303 |
| State | FL |
| Name | Role | Address |
|---|---|---|
| FOX THOMAS | Agent | 1950 BLUEWATER BLVD, NICEVILLE, FL, 32578 |
| Name | Role | Address |
|---|---|---|
| Goeke Bradley Dr. | Secretary | 1950 BLUEWATER BLVD, NICEVILLE, FL, 32578 |
| Name | Role | Address |
|---|---|---|
| FOX THOMAS MDO | President | 1950 BLUEWATER BLVD, NICEVILLE, FL, 32578 |
| Name | Role | Address |
|---|---|---|
| MARKOWSKI WILLIAM JMD | Vice President | 1950 BLUEWATER BLVD, NICEVILLE, FL, 32578 |
| Registration Number | Fictitious Name | Status | Filed Date | Expiration Date | Cancellation Date | Mailing Address |
|---|---|---|---|---|---|---|
| G17000030972 | BLUEWATER ORTHOPEDICS AND REHABILITATION | ACTIVE | 2017-03-23 | 2027-12-31 | No data | 1950 BLUEWATER BLVD., #100, NICEVILLE, FL, 32578 |
| Event Type | Filed Date | Value | Description |
|---|---|---|---|
| CANCEL ADM DISS/REV | 2004-10-28 | No data | No data |
| ADMIN DISSOLUTION FOR ANNUAL REPORT | 2004-10-01 | No data | No data |
| AMENDMENT AND NAME CHANGE | 1995-08-28 | BLUEWATER ORTHOPEDICS, P.A. | No data |
Date of last update: 03 Jan 2025
Sources: Florida Department of State
