Basic Information
| Provider Information | |||||||||
| NPI: | 1437456639 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | FLORIDA WOMAN CARE LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 4205 W ATLANTIC AVE | ||||||||
| Address2: | SUITE C304 | ||||||||
| City: | DELRAY BEACH | ||||||||
| State: | FL | ||||||||
| PostalCode: | 334453901 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5613002410 | ||||||||
| FaxNumber: | 5614955408 | ||||||||
| Practice Location | |||||||||
| Address1: | 600 LAKEVIEW RD | ||||||||
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| City: | CLEARWATER | ||||||||
| State: | FL | ||||||||
| PostalCode: | 337563355 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7274617611 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 02/24/2011 | ||||||||
| LastUpdateDate: | 02/24/2011 | ||||||||
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| AuthorizedOfficialLastName: | KONSKER | ||||||||
| AuthorizedOfficialFirstName: | KENNETH | ||||||||
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| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 5613002410 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | DR. | ||||||||
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| AuthorizedOfficialCredential: | MD | ||||||||
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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 | 001553559 | 05 | FL | MEDICAID |