Basic Information
| Provider Information | |||||||||
| NPI: | 1518360700 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | VARIETY CHILDREN'S HOSPITAL | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | NICKLAUS CHILDREN'S HOSPITAL - AVENTURA CARE CENTER | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3100 SW 62ND AVE | ||||||||
| Address2: | |||||||||
| City: | MIAMI | ||||||||
| State: | FL | ||||||||
| PostalCode: | 331553009 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3056666511 | ||||||||
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| Practice Location | |||||||||
| Address1: | 20295 NE 29TH PL | ||||||||
| Address2: | SUITE 300 | ||||||||
| City: | AVENTURA | ||||||||
| State: | FL | ||||||||
| PostalCode: | 331804109 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7866242800 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/01/2014 | ||||||||
| LastUpdateDate: | 02/22/2022 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| AuthorizedOfficialLastName: | ALFAU | ||||||||
| AuthorizedOfficialFirstName: | GEORGETTE | ||||||||
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| AuthorizedOfficialTitleorPosition: | PAYER CONTRACT/CREDENTIALING ANALYS | ||||||||
| AuthorizedOfficialTelephone: | 7866245795 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | VAREITY CHILDREN HOSPITAL | ||||||||
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| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 02/22/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207T00000X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Neurological Surgery | 207XP3100X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Orthopaedic Surgery | Pediatric Orthopaedic Surgery | 282NC2000X | N | Hospitals | General Acute Care Hospital | Children | 261QU0200X | N | Ambulatory Health Care Facilities | Clinic/Center | Urgent Care | 261QR0400X | N | Ambulatory Health Care Facilities | Clinic/Center | Rehabilitation | 261QR0200X | N | Ambulatory Health Care Facilities | Clinic/Center | Radiology | 2080P0201X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Pediatrics | Pediatric Allergy/Immunology | 2080P0202X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Pediatrics | Pediatric Cardiology | 2080P0205X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Pediatrics | Pediatric Endocrinology | 2080P0206X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Pediatrics | Pediatric Gastroenterology | 2080P0210X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Pediatrics | Pediatric Nephrology | 2080P0216X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Pediatrics | Pediatric Rheumatology | 208200000X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Plastic Surgery | 2085P0229X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Radiology | Pediatric Radiology | 282N00000X | Y | Hospitals | General Acute Care Hospital |
ID Information
| ID | Type | State | Issuer | Description | 010060921 | 05 | FL | MEDICAID |