Basic Information
| Provider Information | |||||||||
| NPI: | 1457026429 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | FWC UROGYNECOOLOGY, LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 5556 | ||||||||
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| City: | BELFAST | ||||||||
| State: | ME | ||||||||
| PostalCode: | 049155500 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5613002410 | ||||||||
| FaxNumber: | 5612357292 | ||||||||
| Practice Location | |||||||||
| Address1: | 2300 S CONGRESS AVE STE 104 | ||||||||
| Address2: | |||||||||
| City: | BOYNTON BEACH | ||||||||
| State: | FL | ||||||||
| PostalCode: | 334267400 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5617520893 | ||||||||
| FaxNumber: | 5617523224 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/12/2021 | ||||||||
| LastUpdateDate: | 09/22/2021 | ||||||||
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| AuthorizedOfficialLastName: | HERNANDEZ | ||||||||
| AuthorizedOfficialFirstName: | ERICA | ||||||||
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| AuthorizedOfficialTitleorPosition: | MANAGER | ||||||||
| AuthorizedOfficialTelephone: | 5613002410 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | OB/GYN SPECIALISTS OF THE PALM BEACHES DBA BOCA PERINATAL ASSOCIATES L | ||||||||
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| NPICertificationDate: | 09/22/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2088F0040X | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Urology | Female Pelvic Medicine and Reconstructive Surgery |
No ID Information.