Basic Information
Provider Information | |||||||||
NPI: | 1760756225 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | VARIETY CHILDREN'S HOSPITAL | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: | NICKLAUS CHILDREN'S MIRAMAR OUTPATIENT CENTER | ||||||||
OtherOrganizationType: | 3 | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 3100 SW 62ND AVE | ||||||||
Address2: |   | ||||||||
City: | MIAMI | ||||||||
State: | FL | ||||||||
PostalCode: | 331553009 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 3056666511 | ||||||||
FaxNumber: |   | ||||||||
Practice Location | |||||||||
Address1: | 12246 MIRAMAR PARKWAY | ||||||||
Address2: |   | ||||||||
City: | MIRAMAR | ||||||||
State: | FL | ||||||||
PostalCode: | 33137 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 3056666511 | ||||||||
FaxNumber: |   | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 03/01/2012 | ||||||||
LastUpdateDate: | 02/22/2022 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | ALFAU | ||||||||
AuthorizedOfficialFirstName: | GEORGETTE | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: | PAYER CONTRACT/CREDENTIALING ANALYS | ||||||||
AuthorizedOfficialTelephone: | 7866245795 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | Y | ||||||||
ParentOrganizationLBN: | VARIETY CHILDREN'S HOSPITAL | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 02/22/2022 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QR0400X |   |   | N |   | Ambulatory Health Care Facilities | Clinic/Center | Rehabilitation | 261QU0200X |   |   | N |   | Ambulatory Health Care Facilities | Clinic/Center | Urgent Care | 282NC2000X |   |   | N |   | Hospitals | General Acute Care Hospital | Children | 261QR0200X |   |   | N |   | Ambulatory Health Care Facilities | Clinic/Center | Radiology | 282N00000X |   |   | Y |   | Hospitals | General Acute Care Hospital |   |
ID Information
ID | Type | State | Issuer | Description | 010060929 | 05 | FL |   | MEDICAID |