Basic Information
Provider Information
NPI: 1306119730
EntityType: 2
ReplacementNPI:  
OrganizationName: VARIETY CHILDREN'S HOSPITAL
LastName:  
FirstName:  
MiddleName:  
NamePrefix:  
NameSuffix:  
Credential:  
OtherOrganizationName: NICKLAUS CHILDREN'S MIAMI LAKES OUTPATIENT CENTER
OtherOrganizationType: 3
OtherLastName:  
OtherFirstName:  
OtherMiddleName:  
OtherNamePrefix:  
OtherNameSuffix:  
OtherCredential:  
OtherLastNameType:  
Mailing Information
Address1: 3100 SW 62ND AVE
Address2:  
City: MIAMI
State: FL
PostalCode: 331553009
CountryCode: US
TelephoneNumber: 3056666511
FaxNumber:  
Practice Location
Address1: 15025 NW 77TH AVE
Address2:  
City: MIAMI LAKES
State: FL
PostalCode: 330146852
CountryCode: US
TelephoneNumber: 3056666511
FaxNumber:  
Other Information
ProviderEnumerationDate: 02/15/2012
LastUpdateDate: 02/22/2022
NPIDeactivationReasonCode:  
NPIDeactivationDate:  
NPIReactivationDate:  
ProviderGenderCode:  
AuthorizedOfficialLastName: ALFAU
AuthorizedOfficialFirstName: GEORGETTE
AuthorizedOfficialMiddleName:  
AuthorizedOfficialTitleorPosition: PAYER CONTRACT/CREDENTIALING ANALYS
AuthorizedOfficialTelephone: 7866245795
IsSoleProprietor:  
IsOrganizationSubpart: Y
ParentOrganizationLBN: VARIETY CHILDREN'S HOSPITAL
AuthorizedOfficialNamePrefix:  
AuthorizedOfficialNameSuffix:  
AuthorizedOfficialCredential:  
NPICertificationDate: 02/22/2022

Taxonomy Information
TaxonomyLicenseStateSwitchTaxonomyGroupTaxonomyTypeTaxonomyClassSubSpecialty
261QR0200X  N Ambulatory Health Care FacilitiesClinic/CenterRadiology
282NC2000X  N HospitalsGeneral Acute Care HospitalChildren
261QR0400X  N Ambulatory Health Care FacilitiesClinic/CenterRehabilitation
261QU0200X  N Ambulatory Health Care FacilitiesClinic/CenterUrgent Care
282N00000X  Y HospitalsGeneral Acute Care Hospital 

ID Information
IDTypeStateIssuerDescription
01006092805FL MEDICAID


Home