1700176013 NPI number — THE MEDICAL GROUP OF SOUTH FLORIDA INC

Table of content: (NPI 1700176013)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1700176013 NPI number — THE MEDICAL GROUP OF SOUTH FLORIDA INC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
THE MEDICAL GROUP 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:
1700176013
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
10/12/2021
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 743533
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
ATLANTA
Provider Business Mailing Address State Name:
GA
Provider Business Mailing Address Postal Code:
30374-3533
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
561-622-1975
Provider Business Mailing Address Fax Number:
855-830-1722

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
4700 N CONGRESS AVE
Provider Second Line Business Practice Location Address:
STE 103
Provider Business Practice Location Address City Name:
WEST PALM BEACH
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
33407-3282
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
561-255-3131
Provider Business Practice Location Address Fax Number:
855-346-3451
Provider Enumeration Date:
04/08/2011

Additional Information

Authorized Official

Authorized Official Last Name:
SMITH
Authorized Official First Name:
JOSHUA
Authorized Official Middle Name:
K
Authorized Official Title or Position:
PRESIDENT/CEO
Authorized Official Telephone Number:
561-622-6111

Provider Taxonomy Codes

  • Taxonomy code: 174400000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 002251800 , issued by the state of ( FL ) . This identifiers is of the category "MEDICAID".




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