1134473663 NPI number — FORT LAUDERDALE MEDICAL SURGICAL ASSOCIATES., INC.

Table of content: (NPI 1134473663)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1134473663 NPI number — FORT LAUDERDALE MEDICAL SURGICAL ASSOCIATES., INC.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
FORT LAUDERDALE MEDICAL SURGICAL ASSOCIATES., 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:
1134473663
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
12/07/2012
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
2301 WILTON DR
Provider Second Line Business Mailing Address:
SUITE C2
Provider Business Mailing Address City Name:
WILTON MANORS
Provider Business Mailing Address State Name:
FL
Provider Business Mailing Address Postal Code:
33305-1202
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
954-567-5898
Provider Business Mailing Address Fax Number:
954-567-0395

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2301 WILTON DR
Provider Second Line Business Practice Location Address:
SUITE C2
Provider Business Practice Location Address City Name:
WILTON MANORS
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
33305-1202
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
954-567-5898
Provider Business Practice Location Address Fax Number:
954-567-0395
Provider Enumeration Date:
11/06/2012

Additional Information

Authorized Official

Authorized Official Last Name:
GOSHEN
Authorized Official First Name:
TIMOTHY
Authorized Official Middle Name:
Authorized Official Title or Position:
OWNER
Authorized Official Telephone Number:
954-567-5898

Provider Taxonomy Codes

  • Taxonomy code: 208C00000X , with the licence number:  OS8504 , 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: 266516600 , issued by the state of ( FL ) . This identifiers is of the category "MEDICAID".
  • Identifier: 57739 . This is a "MEDICARE" identifier . This identifiers is of the category "OTHER".




Copyright © 2007-2025 www.npivalidator.com