Basic Information
| Provider Information | |||||||||
| NPI: | 1376550392 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | SOUTH BROWARD HOSPITAL DISTRICT | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | MEMORIAL DIVISION OF PEDIATRIC CARDIAC SURGERY | ||||||||
| 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: | 1150 N 35TH AVE STE 490 | ||||||||
| Address2: | |||||||||
| City: | HOLLYWOOD | ||||||||
| State: | FL | ||||||||
| PostalCode: | 330215423 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9542653437 | ||||||||
| FaxNumber: | 9542653731 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/02/2006 | ||||||||
| LastUpdateDate: | 04/08/2021 | ||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | SURUJON | ||||||||
| AuthorizedOfficialFirstName: | ESTHER | ||||||||
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| AuthorizedOfficialTitleorPosition: | CFO, MEMORIAL PHYSICIAN GROUP & SBC | ||||||||
| AuthorizedOfficialTelephone: | 9542656677 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | SOUTH BROWARD HOSPITAL DISTRICT | ||||||||
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| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 04/08/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208G00000X | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Thoracic Surgery (Cardiothoracic Vascular Surgery) |
ID Information
| ID | Type | State | Issuer | Description | 009173516 | 05 | FL | MEDICAID | 038184524 | 05 | FL | MEDICAID | 009173576 | 05 | FL | MEDICAID | 009173578 | 05 | FL | MEDICAID |