Basic Information
Provider Information | |||||||||
NPI: | 1982977427 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | VARIETY CHILDREN'S HOSPITAL | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: | NICKLAUS CHILDREN'S HOSPITAL | ||||||||
OtherOrganizationType: | 3 | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | PO BOX 557367 | ||||||||
Address2: |   | ||||||||
City: | MIAMI | ||||||||
State: | FL | ||||||||
PostalCode: | 332557367 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 7866245876 | ||||||||
FaxNumber: | 7866242688 | ||||||||
Practice Location | |||||||||
Address1: | 3100 SW 62ND AVE | ||||||||
Address2: |   | ||||||||
City: | MIAMI | ||||||||
State: | FL | ||||||||
PostalCode: | 331553009 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 3056666511 | ||||||||
FaxNumber: | 3056697123 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 02/14/2012 | ||||||||
LastUpdateDate: | 10/04/2018 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | VIDAURRAZAGA | ||||||||
AuthorizedOfficialFirstName: | RAIZA | ||||||||
AuthorizedOfficialMiddleName: | BEATRIZ | ||||||||
AuthorizedOfficialTitleorPosition: | SR. PROVIDER RELATIONS SPECIALIST | ||||||||
AuthorizedOfficialTelephone: | 7866242186 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | Y | ||||||||
ParentOrganizationLBN: | VARIETY CHILDREN'S HOPSITAL | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QU0200X |   |   | Y |   | Ambulatory Health Care Facilities | Clinic/Center | Urgent Care |
ID Information
ID | Type | State | Issuer | Description | 010060900 | 05 | FL |   | MEDICAID |