1700252624 NPI number — EVIDENCE BASE MEDICAL

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1700252624 NPI number — EVIDENCE BASE MEDICAL

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
EVIDENCE BASE MEDICAL
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:
1700252624
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/14/2015
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
5920 JOHNSON ST
Provider Second Line Business Mailing Address:
SUITE 108
Provider Business Mailing Address City Name:
HOLLYWOOD
Provider Business Mailing Address State Name:
FL
Provider Business Mailing Address Postal Code:
33021-5652
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
954-967-4795
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
5920 JOHNSON ST
Provider Second Line Business Practice Location Address:
SUITE 108
Provider Business Practice Location Address City Name:
HOLLYWOOD
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
33021-5652
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
954-967-4795
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
08/14/2015

Additional Information

Authorized Official

Authorized Official Last Name:
GONZALEZ
Authorized Official First Name:
GONZALO
Authorized Official Middle Name:
Authorized Official Title or Position:
DIRECTOR
Authorized Official Telephone Number:
954-967-4795

Provider Taxonomy Codes

  • Taxonomy code: 207R00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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