Basic Information
| Provider Information | |||||||||
| NPI: | 1376790121 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | VILLAGE GROUP MANAGEMENT CORP. | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
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| Credential: | |||||||||
| OtherOrganizationName: | CENTURY VILLAGE MEDICAL CENTER | ||||||||
| OtherOrganizationType: | 3 | ||||||||
| OtherLastName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | 13550 SW 10TH STREET | ||||||||
| Address2: | STE B | ||||||||
| City: | PEMBROKE PINES | ||||||||
| State: | FL | ||||||||
| PostalCode: | 33027 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9544339501 | ||||||||
| FaxNumber: | 9544338035 | ||||||||
| Practice Location | |||||||||
| Address1: | 13550 SW 10TH STREET | ||||||||
| Address2: | STE B | ||||||||
| City: | PEMBROKE PINES | ||||||||
| State: | FL | ||||||||
| PostalCode: | 33027 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9544339501 | ||||||||
| FaxNumber: | 9544338035 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/24/2008 | ||||||||
| LastUpdateDate: | 10/23/2008 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | GODOY | ||||||||
| AuthorizedOfficialFirstName: | GENE | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | MEDICAL DOCTOR MEDICAL DIRECTOR | ||||||||
| AuthorizedOfficialTelephone: | 9544339501 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | DR. | ||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | M.D. | ||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | ME0065758 | FL | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | K2474 | 01 | FL | VISTA HEALTHPLAN | OTHER | 376822800 | 05 | FL | MEDICAID | 110819 | 01 | FL | HUMANA HEALTHPLAN | OTHER |