Basic Information
| Provider Information | |||||||||
| NPI: | 1467468496 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | SOUTH BROWARD HOSPITAL DISTRICT | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | MEMORIAL DIVISION OF PEDIATRIC NEPHROLOGY | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2900 CORPORATE WAY | ||||||||
| Address2: | DOOR D | ||||||||
| City: | MIRAMAR | ||||||||
| State: | FL | ||||||||
| PostalCode: | 330213925 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9542765685 | ||||||||
| FaxNumber: | 9549857074 | ||||||||
| Practice Location | |||||||||
| Address1: | 1131 N 35TH AVE STE 210 | ||||||||
| Address2: | |||||||||
| City: | HOLLYWOOD | ||||||||
| State: | FL | ||||||||
| PostalCode: | 330215403 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9542659344 | ||||||||
| FaxNumber: | 9542653676 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/31/2006 | ||||||||
| LastUpdateDate: | 01/24/2022 | ||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | SURUJON | ||||||||
| AuthorizedOfficialFirstName: | ESTHER | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | CFO MPG, MPC & UCC | ||||||||
| AuthorizedOfficialTelephone: | 9542656677 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | SOUTH BROWARD HOSPITAL DISTRICT | ||||||||
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| NPICertificationDate: | 01/24/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2080P0210X | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Pediatrics | Pediatric Nephrology |
ID Information
| ID | Type | State | Issuer | Description | 009173539 | 05 | FL | MEDICAID | 038184529 | 05 | FL | MEDICAID | 009173534 | 05 | FL | MEDICAID | 009173536 | 05 | FL | MEDICAID | 108351316 | 05 | FL | MEDICAID |