Basic Information
| Provider Information | |||||||||
| NPI: | 1053061754 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | SOUTH BROWARD HOSPITAL DISTRICT | ||||||||
| LastName: | |||||||||
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| Credential: | |||||||||
| OtherOrganizationName: | MEMORIAL PRIMARY CARE 40 AVENTURA | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2900 CORPORATE WAY | ||||||||
| Address2: | DOOR D | ||||||||
| City: | MIRAMAR | ||||||||
| State: | FL | ||||||||
| PostalCode: | 330253925 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9542765685 | ||||||||
| FaxNumber: | 9549857074 | ||||||||
| Practice Location | |||||||||
| Address1: | 20803 BISCAYNE BLVD STE 204 | ||||||||
| Address2: | |||||||||
| City: | AVENTURA | ||||||||
| State: | FL | ||||||||
| PostalCode: | 331801429 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3056822740 | ||||||||
| FaxNumber: | 9542761043 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/25/2022 | ||||||||
| LastUpdateDate: | 06/01/2022 | ||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | SURUJON | ||||||||
| AuthorizedOfficialFirstName: | ESTHER | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | CFO MPG, MPC AND UCC | ||||||||
| AuthorizedOfficialTelephone: | 9542656677 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | SOUTH BROWARD HOSPITAL DISTRICT | ||||||||
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| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 06/01/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Family Medicine |
No ID Information.