Basic Information
| Provider Information | |||||||||
| NPI: | 1710124912 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | CHUSID | ||||||||
| FirstName: | BRETT | ||||||||
| MiddleName: | AMY | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | PA | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | REISMAN | ||||||||
| OtherFirstName: | BRETT | ||||||||
| OtherMiddleName: | AMY | ||||||||
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| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 2900 CORPORATE WAY | ||||||||
| Address2: | DOOR D | ||||||||
| City: | MIRAMAR | ||||||||
| State: | FL | ||||||||
| PostalCode: | 330253925 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9542765685 | ||||||||
| FaxNumber: | 9549857074 | ||||||||
| Practice Location | |||||||||
| Address1: | 4651 SHERIDAN ST STE 350 | ||||||||
| Address2: | |||||||||
| City: | HOLLYWOOD | ||||||||
| State: | FL | ||||||||
| PostalCode: | 330213425 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9542768559 | ||||||||
| FaxNumber: | 9549669762 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/10/2009 | ||||||||
| LastUpdateDate: | 04/28/2020 | ||||||||
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| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
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| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
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| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
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| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 04/28/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363A00000X | PA9104779 | FL | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |
ID Information
| ID | Type | State | Issuer | Description | 014325500 | 05 | FL | MEDICAID |