BOLLETTIERI SPORTS MEDICINE CENTER
Complete NPI Record 1962574541
Clinic/Center - Physical Therapy in Bradenton, FL
Active since November 15, 2006
Complete NPI Dataset
This page contains the complete raw NPPES record for Bollettieri Sports Medicine Center (NPI 1962574541), a clinic/center organization in Bradenton, FL. All 37 fields on file are listed with their current values and official NPPES definitions, exactly as recorded in the National Plan and Provider Enumeration System. Only fields that contain data are included, so the number of fields shown varies from one NPI record to another.
Use the tools below to filter fields by category, search within the record, or jump straight to a specific field. You can download the full record as a CSV, JSON, or text file, or filter first and export only the fields you need. The Print Clean Summary button produces a printer-friendly copy of the record.
Registry File Document Utilities
- NPI: 1962574541 Field 1/37
- The 10-position all-numeric identification number assigned by the NPS to uniquely identify a health care provider. The NPI number includes an ISO standard check-digit in the 10th position. There is no intelligence about the health care provider in the number.
- Entity Type Code: 2 Field 2/37
- Code describing the type of health care provider that is being assigned an NPI. Codes are 1 = (Person): individual human being who furnishes health care; 2 = (Non-person): entity other than an individual human being that furnishes health care (for example, hospital, SNF, hospital subunit, pharmacy, or HMO).
- Employer Identification Number EIN: Not available Field 3/37
- The Employer Identification Number (EIN), assigned by the IRS, of the provider being identified.
- Provider Organization Name Legal Business Name: BOLLETTIERI SPORTS MEDICINE CENTER Field 4/37
- The name of the organization provider. If the provider is an organization, this is the legal business name.
- Provider First Line Business Mailing Address: 5500 34TH STREET WEST Field 5/37
- The first line mailing address of the provider being identified. This data element may contain the same information as "Provider first line location address".
- Provider Business Mailing Address City Name: BRADENTON Field 6/37
- The city name in the mailing address of the provider being identified.
- Provider Business Mailing Address State Name: FL Field 7/37
- The State or Province name in the mailing address of the provider being identified. This data element may contain the same information as "Provider location address State name".
- Provider Business Mailing Address Postal Code: 342103506 Field 8/37
- The postal ZIP or zone code in the mailing address of the provider being identified. NOTE: ZIP code plus 4-digit extension, if available. This data element may contain the same information as "Provider location address postal code".
- Provider Business Mailing Address Country Code If outside U S : US Field 9/37
- The country code in the mailing address of the provider being identified. This data element may contain the same information as "Provider location address country code".
- Provider Business Mailing Address Telephone Number: 9417550068 Field 10/37
- The telephone number associated with mailing address of the provider being identified. This data element may contain the same information as "Provider location address telephone number".
- Provider Business Mailing Address Fax Number: 9417277502 Field 11/37
- The fax number associated with the mailing address of the provider being identified. This data element may contain the same information as "Provider location address fax number".
- Provider First Line Business Practice Location Address: 5500 34TH STREET WEST Field 12/37
- The first line location address of the provider being identified. For providers with more than one physical location, this is the primary location. This address cannot include a Post Office box.
- Provider Business Practice Location Address City Name: BRADENTON Field 13/37
- The city name in the location address of the provider being identified.
- Provider Business Practice Location Address State Name: FL Field 14/37
- The State code in the location of the provider being identified.
- Provider Business Practice Location Address Postal Code: 342103506 Field 15/37
- The postal ZIP or zone code in the location address of the provider being identified. NOTE: ZIP code plus 4-digit extension, if available.
- Provider Business Practice Location Address Country Code If outside U S : US Field 16/37
- The country code in the location address of the provider being identified.
- Provider Business Practice Location Address Telephone Number: 9417550068 Field 17/37
- The telephone number associated with the location address of the provider being identified.
- Provider Business Practice Location Address Fax Number: 9417277502 Field 18/37
- The fax number associated with the location address of the provider being identified.
- Authorized Official Last Name: FRYE Field 21/37
- The last name of the person authorized to submit the NPI application or to change NPS data for a health care provider.
- Authorized Official First Name: JAY Field 22/37
- The first name of the authorized official.
- Authorized Official Middle Name: S Field 23/37
- The middle name of the authorized official.
- Authorized Official Title or Position: MANAGING PARTNER Field 24/37
- The title or position of the authorized official.
- Authorized Official Telephone Number: 9417550068 Field 25/37
- The 10-position telephone number of the authorized official.
- Healthcare Provider Taxonomy Code 1: 261QP2000X Field 26/37
- This field represents the provider's taxonomy code, which classifies their type, classification, and area of specialization. This code comes from the Healthcare Provider Taxonomy Code Set maintained by the National Uniform Claim Committee (NUCC). The NPS will associate these data with the license data for providers with Entity type code = 1.
- Healthcare Provider Primary Taxonomy Switch 1: Y Field 27/37
- This field shows whether the related taxonomy code is the provider's primary specialty. It is a single-character value: "Y" indicates the taxonomy is the primary one, while "N" indicates it is not. Each provider record can have only one taxonomy code marked as primary.
- Other Provider Identifier 1: Q3B Field 28/37
- An additional identifier number for the provider, either current or previously used. This may include IDs issued by health plans, state agencies, or other organizations. The value is collected from the NPI application or update form.
- Other Provider Identifier Type Code 1: 01 Field 29/37
- A code that specifies the type of additional identifier associated with the provider, either current or past. Examples include UPIN (Universal Provider Identification Number), NSC (National Supplier Clearinghouse), OSCAR (CMS Certification Number), DEA (Drug Enforcement Administration number), state Medicaid ID, or a plan-specific PIN. The value is collected from the NPI application or update form.
- Other Provider Identifier State 1: FL Field 30/37
- The two-letter state code representing the U.S. state or territory that issued the additional provider identifier. This links the Other Provider Identifier to the state where it is valid or was assigned.
- Other Provider Identifier Issuer 1: BLUE CROSS BLUE SHIELD FL Field 31/37
- The name of the organization, agency, or health plan that assigned the additional provider identifier. This identifies who issued the number linked to Other Provider Identifier 1 (for example, a state Medicaid agency, Medicare, or a private insurance company).
- Other Provider Identifier 2: 5864226-003 Field 32/37
- An additional identifier number for the provider, either current or previously used. This may include IDs issued by health plans, state agencies, or other organizations. The value is collected from the NPI application or update form.
- Other Provider Identifier Type Code 2: 01 Field 33/37
- A code that specifies the type of additional identifier associated with the provider, either current or past. Examples include UPIN (Universal Provider Identification Number), NSC (National Supplier Clearinghouse), OSCAR (CMS Certification Number), DEA (Drug Enforcement Administration number), state Medicaid ID, or a plan-specific PIN. The value is collected from the NPI application or update form.
- Other Provider Identifier State 2: FL Field 34/37
- The two-letter state code representing the U.S. state or territory that issued the additional provider identifier. This links the Other Provider Identifier to the state where it is valid or was assigned.
- Other Provider Identifier Issuer 2: CIGNA HEALTHCARE Field 35/37
- The name of the organization, agency, or health plan that assigned the additional provider identifier. This identifies who issued the number linked to Other Provider Identifier 1 (for example, a state Medicaid agency, Medicare, or a private insurance company).
- Is Organization Subpart: N Field 36/37
- Indicates whether the provider is a subpart of a larger organization. This is a single-character code: "Y" means the entity is an organizational subpart, while "N" means it is not. Subparts typically include hospital departments, clinics, or other distinct units that fall under a parent organization.
- Authorized Official Credential Text: PT Field 37/37
- The professional credential(s) of the authorized official listed on the provider's NPI record. Examples include MD (Doctor of Medicine), DO (Doctor of Osteopathy), RN (Registered Nurse), DDS (Doctor of Dental Surgery), PhD, or other recognized designations that reflect the official's qualifications.
Other Provider Identifiers 3
Legacy and payer-issued identifiers reported to the NPPES registry for this provider.
Q3B Other
Identifier 1/3State: FL · Issuer: Blue Cross Blue Shield Fl
Other: An additional provider identifier that does not correspond to any of the other defined identifier type categories.
Other: An additional provider identifier that does not correspond to any of the other defined identifier type categories.
5864226-003 Other
Identifier 2/3State: FL · Issuer: Cigna Healthcare
Other: An additional provider identifier that does not correspond to any of the other defined identifier type categories.
Other: An additional provider identifier that does not correspond to any of the other defined identifier type categories.
686503 Medicare OSCAR/certification
Identifier 3/3State: FL
Medicare OSCAR / Certification Number: Identifies an institutional provider of services (such as a hospital, nursing home, or home health agency) assigned by CMS regional offices or state survey-certification agencies.
Medicare OSCAR / Certification Number: Identifies an institutional provider of services (such as a hospital, nursing home, or home health agency) assigned by CMS regional offices or state survey-certification agencies.
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