1417906561 NPI number — PREMIERE PERINATAL ASSOCIATES

Table of content: (NPI 1417906561)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1417906561 NPI number — PREMIERE PERINATAL ASSOCIATES

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
PREMIERE PERINATAL ASSOCIATES
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:
1417906561
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
09/17/2019
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
500 SE 17TH ST
Provider Second Line Business Mailing Address:
SUITE 100
Provider Business Mailing Address City Name:
FT LAUDERDALE
Provider Business Mailing Address State Name:
FL
Provider Business Mailing Address Postal Code:
33316-2547
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
919-425-1565
Provider Business Mailing Address Fax Number:
919-425-0478

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
200 NW 7TH AVE
Provider Second Line Business Practice Location Address:
PREMIERE PERINATAL ASSOCIATES
Provider Business Practice Location Address City Name:
FT LAUDERDALE
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
33311-9026
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
954-759-6789
Provider Business Practice Location Address Fax Number:
919-425-0478
Provider Enumeration Date:
05/08/2006

Additional Information

Authorized Official

Authorized Official Last Name:
WALLS
Authorized Official First Name:
BERTRAM
Authorized Official Middle Name:
Authorized Official Title or Position:
OWNER/PRESIDENT
Authorized Official Telephone Number:
954-838-2371

Provider Taxonomy Codes

  • Taxonomy code: 207VM0101X , with the licence number:  ME43546 , 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: 273189401 , issued by the state of ( FL ) . This identifiers is of the category "MEDICAID".
  • Identifier: 109649602 . 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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