1912051228 NPI number — OAKRIDGE MEDICAL GROUP

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 1912051228 NPI number — OAKRIDGE MEDICAL GROUP

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
OAKRIDGE MEDICAL GROUP
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:
1912051228
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/22/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1000 NE 56TH ST
Provider Second Line Business Mailing Address:
ATTN BUSINESS OFFICE
Provider Business Mailing Address City Name:
FORT LAUDERDALE
Provider Business Mailing Address State Name:
FL
Provider Business Mailing Address Postal Code:
33334-4149
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
954-958-0606
Provider Business Mailing Address Fax Number:
954-776-0821

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1000 NE 56TH ST
Provider Second Line Business Practice Location Address:
ATTN BUSINESS OFFICE
Provider Business Practice Location Address City Name:
FORT LAUDERDALE
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
33334-4149
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
954-958-0606
Provider Business Practice Location Address Fax Number:
954-776-0821
Provider Enumeration Date:
01/23/2007

Additional Information

Authorized Official

Authorized Official Last Name:
PHANORD
Authorized Official First Name:
FRITZ
Authorized Official Middle Name:
Authorized Official Title or Position:
BUSINESS OFFICE MANAGER
Authorized Official Telephone Number:
954-958-0606

Provider Taxonomy Codes

  • Taxonomy code: 247100000X , with the licence number:  JR3583900 , 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: 7726045 . This is a "AETNA PROVIDER ID" identifier , issued by the state of ( FL ) . This identifiers is of the category "OTHER".
  • Identifier: SG067359 . This is a "VISTA HLTHCR ID" identifier , issued by the state of ( FL ) . This identifiers is of the category "OTHER".
  • Identifier: 498 . This is a "TOTAL HLTH CHOICE ID" identifier , issued by the state of ( FL ) . This identifiers is of the category "OTHER".
  • Identifier: V2224 . This is a "BC BS PROVIDER ID" identifier , issued by the state of ( FL ) . This identifiers is of the category "OTHER".
  • Identifier: 221601 . This is a "FDA#" identifier , issued by the state of ( FL ) . This identifiers is of the category "OTHER".
  • Identifier: 280077 . This is a "AVMED PROVIDER ID" identifier , issued by the state of ( FL ) . This identifiers is of the category "OTHER".
  • Identifier: 00002536540 02 . This is a "UNITED HLTHCR ID" identifier , issued by the state of ( FL ) . This identifiers is of the category "OTHER".
  • Identifier: 214355 . This is a "AMERIGROUP PROVIDER ID" identifier , issued by the state of ( FL ) . This identifiers is of the category "OTHER".




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