Basic Information
| Provider Information | |||||||||
| NPI: | 1457480691 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | SOUTH FLORIDA MEDICAL CENTERS INC | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | AMICUS MEDICAL CENTER | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 14201 W SUNRISE BLVD | ||||||||
| Address2: | UNIT 207 | ||||||||
| City: | SUNRISE | ||||||||
| State: | FL | ||||||||
| PostalCode: | 333233207 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9545055000 | ||||||||
| FaxNumber: | 7542008959 | ||||||||
| Practice Location | |||||||||
| Address1: | 14201 W. SUNRISEBLVD | ||||||||
| Address2: | UNIT 207 | ||||||||
| City: | SUNRISE | ||||||||
| State: | FL | ||||||||
| PostalCode: | 33323 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9545055000 | ||||||||
| FaxNumber: | 9547564442 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/05/2007 | ||||||||
| LastUpdateDate: | 03/06/2013 | ||||||||
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| AuthorizedOfficialLastName: | RODRIGUEZ | ||||||||
| AuthorizedOfficialFirstName: | DAVID | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 9545055000 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | AMICUS MEDICAL CENTER | ||||||||
| AuthorizedOfficialNamePrefix: | MR. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208000000X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Pediatrics | 261QP2300X | HCC9561 | FL | N | Ambulatory Health Care Facilities | Clinic/Center | Primary Care | 261QP2300X | HC9560 | FL | N | Ambulatory Health Care Facilities | Clinic/Center | Primary Care | 207Q00000X | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 260924002 | 05 | FL | MEDICAID | K1476A | 01 | FL | MEDICARE | OTHER | K1476 | 01 | FL | MEDICARE | OTHER | 260924001 | 05 | FL | MEDICAID |