1407805591 NPI number — PHOENIX EMERGENCY MEDICINE OF BROWARD LLC

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 1407805591 NPI number — PHOENIX EMERGENCY MEDICINE OF BROWARD LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
PHOENIX EMERGENCY MEDICINE OF BROWARD LLC
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:
1407805591
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
09/29/2023
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 38048
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
PHILADELPHIA
Provider Business Mailing Address State Name:
PA
Provider Business Mailing Address Postal Code:
19101-0813
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:
201 E SAMPLE RD
Provider Second Line Business Practice Location Address:
PHOENIX EMERGENCY MEDICINE OF BROWARD, LLC
Provider Business Practice Location Address City Name:
POMPANO BEACH
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
33064-3502
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
954-768-6800
Provider Business Practice Location Address Fax Number:
919-425-0478
Provider Enumeration Date:
05/08/2006

Additional Information

Authorized Official

Authorized Official Last Name:
VAUGHN
Authorized Official First Name:
KAREN
Authorized Official Middle Name:
Authorized Official Title or Position:
OFFICER
Authorized Official Telephone Number:
404-450-4684

Provider Taxonomy Codes

  • Taxonomy code: 207P00000X , with the licence number:  ME39895 , registered in the state of FL ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 269118303 , issued by the state of ( FL ) . This identifiers is of the category "MEDICAID".




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