1003019266 NPI number — SHERIDAN DROZDOW HEALTHCARE OF NEVADA PC

Table of content: (NPI 1003019266)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1003019266 NPI number — SHERIDAN DROZDOW HEALTHCARE OF NEVADA PC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
SHERIDAN DROZDOW HEALTHCARE OF NEVADA PC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
SHERIDAN HEALTHCARE OF NEVADA PC
Provider Other Organization Name Type Code:
3
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1003019266
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
03/26/2008
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1613 NW 136TH AVE
Provider Second Line Business Mailing Address:
BUILDING C, SUITE 200
Provider Business Mailing Address City Name:
SUNRISE
Provider Business Mailing Address State Name:
FL
Provider Business Mailing Address Postal Code:
33323-2853
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
6900 NORTH DURANGO DRIVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
LAS VEGAS
Provider Business Practice Location Address State Name:
NV
Provider Business Practice Location Address Postal Code:
89149-4409
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
702-360-9040
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
06/06/2007

Additional Information

Authorized Official

Authorized Official Last Name:
WEISBERG
Authorized Official First Name:
WILLIAM
Authorized Official Middle Name:
Authorized Official Title or Position:
SOLE SHAREHOLDER, OWNER
Authorized Official Telephone Number:
954-838-2371

Provider Taxonomy Codes

  • Taxonomy code: 207L00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 367500000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 1003019266 (GROUP #) , issued by the state of ( NV ) . This identifiers is of the category "MEDICAID".




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