1679583769 NPI number — LAWRENCE E BRODER M D P A

Table of content: (NPI 1679583769)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1679583769 NPI number — LAWRENCE E BRODER M D P A

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
LAWRENCE E BRODER M D 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:
1679583769
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
10/30/2008
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
8740 SW 182ND TER
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
VILLAGE OF PALMETTO BAY
Provider Business Mailing Address State Name:
FL
Provider Business Mailing Address Postal Code:
33157-5952
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
305-238-1212
Provider Business Mailing Address Fax Number:
305-238-8191

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
45 NW 8TH ST
Provider Second Line Business Practice Location Address:
SUITE 104
Provider Business Practice Location Address City Name:
HOMESTEAD
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
33030-4452
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
305-246-5500
Provider Business Practice Location Address Fax Number:
305-246-0081
Provider Enumeration Date:
08/09/2006

Additional Information

Authorized Official

Authorized Official Last Name:
BRODER
Authorized Official First Name:
LAWRENCE
Authorized Official Middle Name:
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
305-238-1212

Provider Taxonomy Codes

  • Taxonomy code: 207RX0202X , with the licence number:  ME0027628 , 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: 210135 . This is a "AMERIGROUP HMO" identifier , issued by the state of ( FL ) . This identifiers is of the category "OTHER".
  • Identifier: 221246 . This is a "AVMED HMO" identifier , issued by the state of ( FL ) . This identifiers is of the category "OTHER".
  • Identifier: 370009700 , issued by the state of ( FL ) . This identifiers is of the category "MEDICAID".
  • Identifier: 55027 . This is a "JMH HMO" identifier , issued by the state of ( FL ) . This identifiers is of the category "OTHER".




Copyright © 2007-2025 www.npivalidator.com