Basic Information
| Provider Information | |||||||||
| NPI: | 1063704559 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | SOUTH BROWARD HOSPITAL DISTRICT | ||||||||
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| OtherOrganizationName: | MEMORIAL DIVISION OF PEDIATRIC OTOLARYANGOLOGY | ||||||||
| 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: | 1131 N 35TH AVE STE 300 | ||||||||
| Address2: | |||||||||
| City: | HOLLYWOOD | ||||||||
| State: | FL | ||||||||
| PostalCode: | 330215403 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9542653030 | ||||||||
| FaxNumber: | 9548936301 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/03/2011 | ||||||||
| LastUpdateDate: | 03/17/2018 | ||||||||
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| AuthorizedOfficialLastName: | BEAUCHESNE | ||||||||
| AuthorizedOfficialFirstName: | NINA | ||||||||
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| AuthorizedOfficialTitleorPosition: | SR VICE PRESIDENT MHS | ||||||||
| AuthorizedOfficialTelephone: | 9542656996 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | SOUTH BROWARD HOSPITAL DISTRICT | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207YP0228X | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Otolaryngology | Pediatric Otolaryngology |
ID Information
| ID | Type | State | Issuer | Description | 038184538 | 05 | FL | MEDICAID |