Basic Information
| Provider Information | |||||||||
| NPI: | 1871521880 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | INPHYNET SOUTH BROWARD LLC | ||||||||
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| OtherOrganizationName: | INPHYNET SOUTH BROWARD INC | ||||||||
| OtherOrganizationType: | 4 | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 635002 | ||||||||
| Address2: | |||||||||
| City: | CINCINNATI | ||||||||
| State: | OH | ||||||||
| PostalCode: | 452635002 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8004243672 | ||||||||
| FaxNumber: | 9543773042 | ||||||||
| Practice Location | |||||||||
| Address1: | 3501 JOHNSON STREET | ||||||||
| Address2: | |||||||||
| City: | HOLLYWOOD | ||||||||
| State: | FL | ||||||||
| PostalCode: | 330213302 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9549872000 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 06/29/2006 | ||||||||
| LastUpdateDate: | 09/10/2020 | ||||||||
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| AuthorizedOfficialLastName: | CORVINI | ||||||||
| AuthorizedOfficialFirstName: | MICHAEL | ||||||||
| AuthorizedOfficialMiddleName: | D | ||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 8136355855 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | MD | ||||||||
| NPICertificationDate: | 09/10/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207PP0204X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Emergency Medicine | Pediatric Emergency Medicine | 207Q00000X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Family Medicine | 2080P0204X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Pediatrics | Pediatric Emergency Medicine | 2084P0800X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Psychiatry | 363A00000X | N | 193200000X MULTI-SPECIALTY GROUP | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | 363L00000X | N | 193200000X MULTI-SPECIALTY GROUP | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | 207P00000X | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Emergency Medicine |
ID Information
| ID | Type | State | Issuer | Description | 170128100 | 01 | FL | US DEPT OF LABOR | OTHER | 251537701 | 05 | FL | MEDICAID | 251537704 | 05 | FL | MEDICAID | 251537705 | 05 | FL | MEDICAID | CD7742 | 01 | FL | MEDICARE TRAVELERS RR - G | OTHER | 251537700 | 05 | FL | MEDICAID | 251537702 | 05 | FL | MEDICAID | 170128101 | 01 | FL | US DEPT | OTHER | 21223 | 01 | FL | BS FL | OTHER | 251537703 | 05 | FL | MEDICAID |