1740771708 NPI number — EAST FORT LAUDERDALE ASC LLC

Table of content: (NPI 1740771708)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1740771708 NPI number — EAST FORT LAUDERDALE ASC LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
EAST FORT LAUDERDALE ASC LLC
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:
6
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:
1740771708
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
11/03/2023
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
DEPT #6032
Provider Second Line Business Mailing Address:
PO BOX 4417
Provider Business Mailing Address City Name:
HOUSTON
Provider Business Mailing Address State Name:
TX
Provider Business Mailing Address Postal Code:
77210-4417
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
610-644-8900
Provider Business Mailing Address Fax Number:
610-537-6059

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1925 NE 45TH ST STE 100
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
FT LAUDERDALE
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
33308-5158
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
954-651-9847
Provider Business Practice Location Address Fax Number:
954-990-6191
Provider Enumeration Date:
05/25/2018

Additional Information

Authorized Official

Authorized Official Last Name:
MILLER
Authorized Official First Name:
GREGG
Authorized Official Middle Name:
Authorized Official Title or Position:
SR. VICE PRESIDENT
Authorized Official Telephone Number:
610-644-8900

Provider Taxonomy Codes

  • Taxonomy code: 261QA1903X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 103182900 . 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