Basic Information
| Provider Information | |||||||||
| NPI: | 1144270109 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | SOUTH COUNTY UROLOGY PA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 5258 LINTON BLVD | ||||||||
| Address2: | SUITE 203 | ||||||||
| City: | DELRAY BEACH | ||||||||
| State: | FL | ||||||||
| PostalCode: | 334846540 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5614957570 | ||||||||
| FaxNumber: | 5614967074 | ||||||||
| Practice Location | |||||||||
| Address1: | 5258 LINTON BLVD | ||||||||
| Address2: | SUITE 203 | ||||||||
| City: | DELRAY BEACH | ||||||||
| State: | FL | ||||||||
| PostalCode: | 334846540 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5614957570 | ||||||||
| FaxNumber: | 5614967074 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/11/2006 | ||||||||
| LastUpdateDate: | 08/16/2011 | ||||||||
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| AuthorizedOfficialLastName: | ZIFFER | ||||||||
| AuthorizedOfficialFirstName: | MARK | ||||||||
| AuthorizedOfficialMiddleName: | D | ||||||||
| AuthorizedOfficialTitleorPosition: | OWNER | ||||||||
| AuthorizedOfficialTelephone: | 5614957570 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | MD | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208800000X | ME 46004 | FL | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Urology |
ID Information
| ID | Type | State | Issuer | Description | 9682429 | 01 | FL | GHI | OTHER | 21423 | 01 | FL | BLUE CROSS BLUE SHIELD | OTHER | DG5614 | 01 | FL | RAILROAD MEDICARE | OTHER |