Basic Information
Provider Information | |||||||||
NPI: | 1053362665 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | PRIMARY CARE PHYSICIANS OF HOLLYWOOD, PL | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 2488 N UNIVERSITY DR | ||||||||
Address2: |   | ||||||||
City: | PEMBROKE PINES | ||||||||
State: | FL | ||||||||
PostalCode: | 330243624 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 9549839191 | ||||||||
FaxNumber: | 9549831152 | ||||||||
Practice Location | |||||||||
Address1: | 2488 N UNIVERSITY DR | ||||||||
Address2: |   | ||||||||
City: | PEMBROKE PINES | ||||||||
State: | FL | ||||||||
PostalCode: | 330243624 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 9549839191 | ||||||||
FaxNumber: | 9549831152 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 05/16/2006 | ||||||||
LastUpdateDate: | 09/13/2018 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | BURKE | ||||||||
AuthorizedOfficialFirstName: | LAURA | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: | CREDENTIALING MANGER | ||||||||
AuthorizedOfficialTelephone: | 9545634472 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | ME 74548 | FL | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Family Medicine |   | 207R00000X | ME 81676 | FL | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine |   | 207R00000X |   |   | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine |   |
ID Information
ID | Type | State | Issuer | Description | 39480 | 01 | FL | BCBS | OTHER | 269366600 | 05 | FL |   | MEDICAID |