Basic Information
Provider Information | |||||||||
NPI: | 1306037221 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | PHYSICIAN HEALTH CARE SYSTEM, LLC | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 7800 W OAKLAND PARK BLVD | ||||||||
Address2: | SUITE E-214 | ||||||||
City: | SUNRISE | ||||||||
State: | FL | ||||||||
PostalCode: | 333516741 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 9543186590 | ||||||||
FaxNumber: | 9543186599 | ||||||||
Practice Location | |||||||||
Address1: | 7401 N UNIVERSITY DR | ||||||||
Address2: | SUITE 105 | ||||||||
City: | TAMARAC | ||||||||
State: | FL | ||||||||
PostalCode: | 333212979 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 9547225353 | ||||||||
FaxNumber: | 9547220132 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 08/06/2007 | ||||||||
LastUpdateDate: | 04/20/2008 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | DI CAPUA | ||||||||
AuthorizedOfficialFirstName: | JOSEPH | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: | CEO | ||||||||
AuthorizedOfficialTelephone: | 9543186590 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: | MR. | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X |   |   | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Family Medicine |   |
No ID Information.