Basic Information
| Provider Information | |||||||||
| NPI: | 1053657650 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | MEMORIAL DIVISION OF PEDIATRIC OTOLARYNGOLOGY | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1150 N 35TH AVE | ||||||||
| Address2: | SUITE 490 | ||||||||
| City: | HOLLYWOOD | ||||||||
| State: | FL | ||||||||
| PostalCode: | 330215424 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9542651616 | ||||||||
| FaxNumber: | 9548936325 | ||||||||
| Practice Location | |||||||||
| Address1: | 1150 N 35TH AVE | ||||||||
| Address2: | SUITE 490 | ||||||||
| City: | HOLLYWOOD | ||||||||
| State: | FL | ||||||||
| PostalCode: | 330215424 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9542651616 | ||||||||
| FaxNumber: | 9548936325 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/31/2012 | ||||||||
| LastUpdateDate: | 12/31/2012 | ||||||||
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| AuthorizedOfficialLastName: | OSTROWER | ||||||||
| AuthorizedOfficialFirstName: | SAMUEL | ||||||||
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| AuthorizedOfficialTitleorPosition: | OTOLARYNGOLOGIST | ||||||||
| AuthorizedOfficialTelephone: | 9542651616 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | DR. | ||||||||
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| AuthorizedOfficialCredential: | M.D | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363A00000X | PA9106938 | FL | Y | 193400000X SINGLE SPECIALTY GROUP | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |
ID Information
| ID | Type | State | Issuer | Description | PA9106938 | 01 | FL | MEDICAL LICENSE | OTHER |