Basic Information
| Provider Information | |||||||||
| NPI: | 1083807507 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | METCARE OF FLORIDA INC. | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | METCARE OF NEW SMYRNA BEACH | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 250 S AUSTRALIAN AVE | ||||||||
| Address2: | SUITE 400 | ||||||||
| City: | WEST PALM BEACH | ||||||||
| State: | FL | ||||||||
| PostalCode: | 334015018 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5618058500 | ||||||||
| FaxNumber: | 5618058501 | ||||||||
| Practice Location | |||||||||
| Address1: | 1722 STATE ROAD 44 | ||||||||
| Address2: | |||||||||
| City: | NEW SMYRNA BEACH | ||||||||
| State: | FL | ||||||||
| PostalCode: | 321688339 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3864283241 | ||||||||
| FaxNumber: | 9864278440 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/20/2007 | ||||||||
| LastUpdateDate: | 08/20/2007 | ||||||||
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| AuthorizedOfficialLastName: | SABO | ||||||||
| AuthorizedOfficialFirstName: | ROBERT | ||||||||
| AuthorizedOfficialMiddleName: | J | ||||||||
| AuthorizedOfficialTitleorPosition: | CHIEF FINANCIAL OFFICER | ||||||||
| AuthorizedOfficialTelephone: | 5618058500 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | METROPOLITAN HEALTH NETWORKS | ||||||||
| AuthorizedOfficialNamePrefix: | MR. | ||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine |
ID Information
| ID | Type | State | Issuer | Description | 40730B | 01 | FL | MECICARE | OTHER | 40730 | 01 | FL | MEDICARE | OTHER | 40730A | 01 | FL | MEDICARE | OTHER |