Basic Information
| Provider Information | |||||||||
| NPI: | 1134642465 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | EBENEZER MEDICAL CENTER LLC | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | EBENEZERMED | ||||||||
| OtherOrganizationType: | 4 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 646 W PALM DR | ||||||||
| Address2: | |||||||||
| City: | HOMESTEAD | ||||||||
| State: | FL | ||||||||
| PostalCode: | 330343208 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3053305393 | ||||||||
| FaxNumber: | 3057730220 | ||||||||
| Practice Location | |||||||||
| Address1: | 646 W PALM DR | ||||||||
| Address2: | |||||||||
| City: | HOMESTEAD | ||||||||
| State: | FL | ||||||||
| PostalCode: | 330343208 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3053305393 | ||||||||
| FaxNumber: | 3057730220 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/18/2017 | ||||||||
| LastUpdateDate: | 07/21/2022 | ||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | DISOTUAR ABAD | ||||||||
| AuthorizedOfficialFirstName: | RENE | ||||||||
| AuthorizedOfficialMiddleName: | ELADIO | ||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 3053305393 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | MD | ||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QP2300X | Y | Ambulatory Health Care Facilities | Clinic/Center | Primary Care |
ID Information
| ID | Type | State | Issuer | Description | 010733300 | 05 | FL | MEDICAID |