Basic Information
Provider Information | |||||||||
NPI: | 1316244502 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | FLORIDA WOMAN CARE, LLC | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 4205 W ATLANTIC AVE | ||||||||
Address2: | SUITE C-304 | ||||||||
City: | DELRAY BEACH | ||||||||
State: | FL | ||||||||
PostalCode: | 334453901 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 5613002410 | ||||||||
FaxNumber: | 5614955408 | ||||||||
Practice Location | |||||||||
Address1: | 1925 MIZELL AVE | ||||||||
Address2: | SUITE 206 | ||||||||
City: | WINTER PARK | ||||||||
State: | FL | ||||||||
PostalCode: | 327924155 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 4076453055 | ||||||||
FaxNumber: | 4076475125 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 02/24/2011 | ||||||||
LastUpdateDate: | 03/04/2011 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | KONSKER | ||||||||
AuthorizedOfficialFirstName: | KENNETH | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
AuthorizedOfficialTelephone: | 5613002410 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: | DR. | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: | MD | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207V00000X |   |   | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Obstetrics & Gynecology |   |
ID Information
ID | Type | State | Issuer | Description | 001553506 | 05 | FL |   | MEDICAID |