Basic Information
| Provider Information | |||||||||
| NPI: | 1467690263 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | SOUTH FLORIDA GROUP SERVICES LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 5665 NEW NORTHSIDE DR NW | ||||||||
| Address2: | SUITE 320 | ||||||||
| City: | ATLANTA | ||||||||
| State: | GA | ||||||||
| PostalCode: | 303285831 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7708745400 | ||||||||
| FaxNumber: | 7708745483 | ||||||||
| Practice Location | |||||||||
| Address1: | 3100 S DOUGLAS RD | ||||||||
| Address2: | |||||||||
| City: | CORAL GABLES | ||||||||
| State: | FL | ||||||||
| PostalCode: | 331346914 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3054458461 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 02/02/2009 | ||||||||
| LastUpdateDate: | 08/06/2010 | ||||||||
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| AuthorizedOfficialLastName: | MURRAY | ||||||||
| AuthorizedOfficialFirstName: | ROGER | ||||||||
| AuthorizedOfficialMiddleName: | PAUL | ||||||||
| AuthorizedOfficialTitleorPosition: | CHIEF OPERATING OFFICER | ||||||||
| AuthorizedOfficialTelephone: | 7708745400 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MR. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207L00000X | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Anesthesiology |
ID Information
| ID | Type | State | Issuer | Description | 000795800 | 05 | FL | MEDICAID |