Basic Information
| Provider Information | |||||||||
| NPI: | 1437434735 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | OPTUMCARE SOUTH FLORIDA, LLC | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | OPTUM | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 5130 SUNFOREST DR STE 300 | ||||||||
| Address2: | |||||||||
| City: | TAMPA | ||||||||
| State: | FL | ||||||||
| PostalCode: | 336346327 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7278240780 | ||||||||
| FaxNumber: | 8135148891 | ||||||||
| Practice Location | |||||||||
| Address1: | 5130 SUNFOREST DR STE 300 | ||||||||
| Address2: | |||||||||
| City: | TAMPA | ||||||||
| State: | FL | ||||||||
| PostalCode: | 336346327 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7278240780 | ||||||||
| FaxNumber: | 8135148891 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/18/2011 | ||||||||
| LastUpdateDate: | 11/24/2021 | ||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | LIETHEN | ||||||||
| AuthorizedOfficialFirstName: | JOHN | ||||||||
| AuthorizedOfficialMiddleName: | G. | ||||||||
| AuthorizedOfficialTitleorPosition: | SECRETARY | ||||||||
| AuthorizedOfficialTelephone: | 9522056262 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 11/24/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Family Medicine | 207R00000X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine | 208D00000X | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | General Practice |
ID Information
| ID | Type | State | Issuer | Description | 004371300 | 05 | FL | MEDICAID |