1487624771 NPI number — SPORTS MEDICINE ASSOCIATES OF SOUTH FLORIDA, P.A.

Table of content: (NPI 1487624771)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1487624771 NPI number — SPORTS MEDICINE ASSOCIATES OF SOUTH FLORIDA, P.A.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
SPORTS MEDICINE ASSOCIATES OF SOUTH FLORIDA, P.A.
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:
1487624771
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
09/24/2024
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
220 SW 84TH AVE STE 102
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
PLANTATION
Provider Business Mailing Address State Name:
FL
Provider Business Mailing Address Postal Code:
33324-2729
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
954-349-2345
Provider Business Mailing Address Fax Number:
954-641-1086

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
220 SW 84TH AVE STE 102
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
PLANTATION
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
33324-2729
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
954-720-1530
Provider Business Practice Location Address Fax Number:
954-720-6540
Provider Enumeration Date:
01/26/2006

Additional Information

Authorized Official

Authorized Official Last Name:
HERRERA
Authorized Official First Name:
CHRYSTAL
Authorized Official Middle Name:
A.
Authorized Official Title or Position:
CREDENTIALING COORDINATOR
Authorized Official Telephone Number:
305-218-6965

Provider Taxonomy Codes

  • Taxonomy code: 207X00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 207XS0106X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 207XX0005X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 208100000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 363A00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

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

  • Identifier: 108857600 . This is a "MEDICAID - SYDNEE R. BRIN, PA-C" identifier , issued by the state of ( FL ) . This identifiers is of the category "OTHER".
  • Identifier: 002603000 . This is a "MEDICAID - PAUL R. BUCHANAN, PA-C" identifier , issued by the state of ( FL ) . This identifiers is of the category "OTHER".
  • Identifier: 1558022426 . This is a "MEDICAID - HANNA E. HEMMATI, PA-C" identifier , issued by the state of ( FL ) . This identifiers is of the category "OTHER".
  • Identifier: 002398700 . This is a "MEDICAID - ALEXANDER J. BERTOT, M.D." identifier , issued by the state of ( FL ) . This identifiers is of the category "OTHER".
  • Identifier: 002876700 , issued by the state of ( FL ) . This identifiers is of the category "MEDICAID".
  • Identifier: 002602400 . This is a "MEDICAID - ERIC D. BRONSON, PA-C" identifier , issued by the state of ( FL ) . This identifiers is of the category "OTHER".
  • Identifier: 002462700 . This is a "MEDICAID - DAVID SHENASSA, M.D." identifier , issued by the state of ( FL ) . This identifiers is of the category "OTHER".
  • Identifier: 118651300 . This is a "MEDICAID - JESSE T. CROSNO, PA-C" identifier , issued by the state of ( FL ) . This identifiers is of the category "OTHER".
  • Identifier: 002615000 . This is a "MEDICAID - ALFRED A. DESIMONE, M.D." identifier , issued by the state of ( FL ) . This identifiers is of the category "OTHER".
  • Identifier: 119205700 . This is a "MEDICAID - PEDRO A. RICART HOFFIZ, M.D." identifier , issued by the state of ( FL ) . This identifiers is of the category "OTHER".
  • Identifier: 002876700 . This is a "Florida Medicaid Provider ID" identifier , issued by the state of ( FL ) . This identifiers is of the category "MEDICAID".




Copyright © 2007-2025 www.npivalidator.com