1346254158 NPI number — PALMETTO FERTILITY CENTER OF SOUTH FLORIDA, INC

Table of content: (NPI 1346254158)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1346254158 NPI number — PALMETTO FERTILITY CENTER OF SOUTH FLORIDA, INC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
PALMETTO FERTILITY CENTER OF SOUTH FLORIDA, 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:
1346254158
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/22/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
7100 W 20TH AVE
Provider Second Line Business Mailing Address:
SUITE 205
Provider Business Mailing Address City Name:
HIALEAH
Provider Business Mailing Address State Name:
FL
Provider Business Mailing Address Postal Code:
33016-1897
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
305-558-0808
Provider Business Mailing Address Fax Number:
305-558-0806

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1951 SW 172ND AVE
Provider Second Line Business Practice Location Address:
SUITE 412
Provider Business Practice Location Address City Name:
MIRAMAR
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
33029-5593
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
954-538-1440
Provider Business Practice Location Address Fax Number:
954-447-5028
Provider Enumeration Date:
07/28/2006

Additional Information

Authorized Official

Authorized Official Last Name:
GRAUBERT
Authorized Official First Name:
MICHAEL
Authorized Official Middle Name:
DAVID
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
305-558-0808

Provider Taxonomy Codes

  • Taxonomy code: 207VE0102X , with the licence number:  72801 , 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)





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