Basic Information
| Provider Information | |||||||||
| NPI: | 1093132169 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | SOUTH BROWARD HOSPITAL DISTRICT | ||||||||
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| OtherOrganizationName: | MEMORIAL DIVISION OF UROLOGY | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2900 CORPORATE WAY | ||||||||
| Address2: | MPG DOOR D | ||||||||
| City: | MIRAMAR | ||||||||
| State: | FL | ||||||||
| PostalCode: | 330253925 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9542765581 | ||||||||
| FaxNumber: | 9549857074 | ||||||||
| Practice Location | |||||||||
| Address1: | 20801 BISCAYNE BLVD | ||||||||
| Address2: | SUITE 203 | ||||||||
| City: | AVENTURA | ||||||||
| State: | FL | ||||||||
| PostalCode: | 331801430 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9542765615 | ||||||||
| FaxNumber: | 9549857074 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/26/2014 | ||||||||
| LastUpdateDate: | 04/22/2014 | ||||||||
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| AuthorizedOfficialLastName: | BEAUCHESNE | ||||||||
| AuthorizedOfficialFirstName: | NINA | ||||||||
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| AuthorizedOfficialTitleorPosition: | SR VICE PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 9542656996 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MRS. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208800000X | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Urology |
No ID Information.