Basic Information
| Provider Information | |||||||||
| NPI: | 1205270907 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | SOUTH BROWARD HOSPITAL DISTRICT | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | MEMORIAL DIVISION OF PEDIATRIC NEUROSURGERY | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 4651 SHERIDAN ST | ||||||||
| Address2: | SUITE 150 | ||||||||
| City: | HOLLYWOOD | ||||||||
| State: | FL | ||||||||
| PostalCode: | 33021 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9542653500 | ||||||||
| FaxNumber: | 9549890454 | ||||||||
| Practice Location | |||||||||
| Address1: | 4650 SHERIDAN ST | ||||||||
| Address2: | SUITE 150 | ||||||||
| City: | HOLLYWOOD | ||||||||
| State: | FL | ||||||||
| PostalCode: | 33021 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9542653500 | ||||||||
| FaxNumber: | 9549890454 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/24/2013 | ||||||||
| LastUpdateDate: | 04/24/2013 | ||||||||
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| AuthorizedOfficialLastName: | SALCEDA | ||||||||
| AuthorizedOfficialFirstName: | MARIO | ||||||||
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| AuthorizedOfficialTitleorPosition: | ADMINISTRATOR | ||||||||
| AuthorizedOfficialTelephone: | 9542765572 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | SOUTH BROWARD HOSPITAL DISTRICT | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207T00000X | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Neurological Surgery |
No ID Information.