Basic Information
| Provider Information | |||||||||
| NPI: | 1447345517 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | NOVA SOUTHEASTERN UNIVERSITY, INC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3200 SOUTH UNIVERSITY DRIVE | ||||||||
| Address2: | SANFORD L. ZIFF BLDG. 3RD FLOOR ROOM 4364-D | ||||||||
| City: | FT. LAUDERDALE | ||||||||
| State: | FL | ||||||||
| PostalCode: | 333282018 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9542624343 | ||||||||
| FaxNumber: | 9542622269 | ||||||||
| Practice Location | |||||||||
| Address1: | 3200 SOUTH UNIVERSITY DRIVE | ||||||||
| Address2: | SANFORD L. ZIFF BLDG. | ||||||||
| City: | FT. LAUDERDALE | ||||||||
| State: | FL | ||||||||
| PostalCode: | 333282018 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9542624100 | ||||||||
| FaxNumber: | 9542622271 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/04/2006 | ||||||||
| LastUpdateDate: | 01/07/2020 | ||||||||
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| AuthorizedOfficialLastName: | OLLER | ||||||||
| AuthorizedOfficialFirstName: | ROBERT | ||||||||
| AuthorizedOfficialMiddleName: | S | ||||||||
| AuthorizedOfficialTitleorPosition: | CLINICAL OPERATIONS | ||||||||
| AuthorizedOfficialTelephone: | 9542624343 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | NOVA SOUTHEASTEN UNIVERSITY, INC | ||||||||
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| AuthorizedOfficialCredential: | CEO | ||||||||
| NPICertificationDate: | 01/07/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208000000X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Pediatrics | 2085R0202X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Radiology | Diagnostic Radiology | 2085U0001X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Radiology | Diagnostic Ultrasound | 207N00000X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Dermatology | 207R00000X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine | 207RN0300X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine | Nephrology | 207V00000X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Obstetrics & Gynecology | 207Q00000X | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 062133100 | 05 | FL | MEDICAID |