Basic Information
| Provider Information | |||||||||
| NPI: | 1669713673 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | SOUTH BROWARD HOSPITAL DISTRICT | ||||||||
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| OtherOrganizationName: | MEMORIAL DIVISION OF GENERAL SURGERY | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2900 CORPORATE WAY | ||||||||
| Address2: | DOOR D | ||||||||
| City: | MIRAMAR | ||||||||
| State: | FL | ||||||||
| PostalCode: | 330253925 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9542765685 | ||||||||
| FaxNumber: | 9549857074 | ||||||||
| Practice Location | |||||||||
| Address1: | 601 N FLAMINGO RD STE 409 | ||||||||
| Address2: | |||||||||
| City: | PEMBROKE PINES | ||||||||
| State: | FL | ||||||||
| PostalCode: | 330281012 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9548444480 | ||||||||
| FaxNumber: | 9544475344 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/15/2013 | ||||||||
| LastUpdateDate: | 08/24/2022 | ||||||||
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| AuthorizedOfficialLastName: | SURUJON | ||||||||
| AuthorizedOfficialFirstName: | ESTHER | ||||||||
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| AuthorizedOfficialTitleorPosition: | CFO MPG MPC UCC | ||||||||
| AuthorizedOfficialTelephone: | 9542656677 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | SOUTH BROWARD HOSPITAL DISTRICT | ||||||||
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| NPICertificationDate: | 08/24/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208600000X | ME79004 | FL | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Surgery | 2086X0206X | ME80863 | FL | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Surgery | Surgical Oncology | 208C00000X | ME55793 | FL | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Colon & Rectal Surgery | 208600000X | ME47069 | FL | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Surgery |
No ID Information.