Basic Information
| Provider Information | |||||||||
| NPI: | 1962706721 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | SOUTH BROWARD HOSPITAL DISTRICT | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2900 CORPORATE WAY | ||||||||
| Address2: | MPG DOOR D | ||||||||
| City: | MIRAMAR | ||||||||
| State: | FL | ||||||||
| PostalCode: | 330253925 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9542765685 | ||||||||
| FaxNumber: | 9549857074 | ||||||||
| Practice Location | |||||||||
| Address1: | 1150 N 35TH AVE | ||||||||
| Address2: | SUITE 520 | ||||||||
| City: | HOLLYWOOD | ||||||||
| State: | FL | ||||||||
| PostalCode: | 33021 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9542652423 | ||||||||
| FaxNumber: | 9549614860 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/07/2011 | ||||||||
| LastUpdateDate: | 03/06/2020 | ||||||||
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| AuthorizedOfficialLastName: | SURUJON | ||||||||
| AuthorizedOfficialFirstName: | ESTHER | ||||||||
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| AuthorizedOfficialTitleorPosition: | CFO MEMORIAL PHYSICIAN GROUP & MPC | ||||||||
| AuthorizedOfficialTelephone: | 9542656677 | ||||||||
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| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | SOUTH BROWARD HOSPITAL DISTRICT | ||||||||
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| NPICertificationDate: | 03/06/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2084N0402X | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Neurology with Special Qualifications in Child Neurology |
No ID Information.