Basic Information
Provider Information | |||||||||
NPI: | 1568030138 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | SOUTH BROWARD HOSPITAL DISTRICT | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: | MEMORIAL DIVISION OF PEDIATRIC REHABILITATION | ||||||||
OtherOrganizationType: | 3 | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 2900 CORPORATE WAY | ||||||||
Address2: | DOOR D | ||||||||
City: | MIRAMAR | ||||||||
State: | FL | ||||||||
PostalCode: | 330253925 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 9542765685 | ||||||||
FaxNumber: | 9549857074 | ||||||||
Practice Location | |||||||||
Address1: | 3377 S STATE ROAD 7 | ||||||||
Address2: |   | ||||||||
City: | WELLINGTON | ||||||||
State: | FL | ||||||||
PostalCode: | 334498082 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 9542761600 | ||||||||
FaxNumber: | 9548936244 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 06/11/2021 | ||||||||
LastUpdateDate: | 07/28/2021 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | SURUJON | ||||||||
AuthorizedOfficialFirstName: | ESTHER | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: | CFO MEMORIAL PHYSICIAN GROUP & MPC | ||||||||
AuthorizedOfficialTelephone: | 9542656677 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | Y | ||||||||
ParentOrganizationLBN: | SOUTH BROWARD HOSPITAL DISTRICT | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 07/28/2021 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2081P0010X |   |   | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Physical Medicine & Rehabilitation | Pediatric Rehabilitation Medicine |
No ID Information.