1245773779 NPI number — NOVA SOUHTEASTERN UNIVERSITY, INC

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1245773779 NPI number — NOVA SOUHTEASTERN UNIVERSITY, INC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
NOVA SOUHTEASTERN UNIVERSITY, INC
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:
Provider Other Organization Name Type Code:
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:
1245773779
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
05/26/2023
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1201 W CYPRESS CREEK RD
Provider Second Line Business Mailing Address:
2ND FLOOR SUITE 102
Provider Business Mailing Address City Name:
FORT LAUDERDALE
Provider Business Mailing Address State Name:
FL
Provider Business Mailing Address Postal Code:
33309-1906
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
954-262-7530
Provider Business Mailing Address Fax Number:
954-568-7749

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1201 W CYPRESS CREEK RD
Provider Second Line Business Practice Location Address:
2ND FLOOR SUITE 102
Provider Business Practice Location Address City Name:
FORT LAUDERDALE
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
33309-1906
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
954-262-7530
Provider Business Practice Location Address Fax Number:
954-568-7749
Provider Enumeration Date:
12/01/2016

Additional Information

Authorized Official

Authorized Official Last Name:
ESTEVEZ
Authorized Official First Name:
ROSEMERY
Authorized Official Middle Name:
Authorized Official Title or Position:
DIR OF CONTRACTING AND CRED
Authorized Official Telephone Number:
954-262-4343

Provider Taxonomy Codes

  • Taxonomy code: 122300000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 104693707 . This is a "Florida Medicaid Provider ID" identifier , issued by the state of ( FL ) . This identifiers is of the category "MEDICAID".




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