Basic Information
| Provider Information | |||||||||
| NPI: | 1487962098 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | PEMBROKE PAVILION PSYCHIATRIC ASSOCIATES, INC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1000 N HIATUS RD | ||||||||
| Address2: | SUITE 140 | ||||||||
| City: | PEMBROKE PINES | ||||||||
| State: | FL | ||||||||
| PostalCode: | 330263097 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9544319838 | ||||||||
| FaxNumber: | 9544337066 | ||||||||
| Practice Location | |||||||||
| Address1: | 1000 N HIATUS RD | ||||||||
| Address2: | SUITE 140 | ||||||||
| City: | PEMBROKE PINES | ||||||||
| State: | FL | ||||||||
| PostalCode: | 330263097 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9544319838 | ||||||||
| FaxNumber: | 9544337066 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/16/2010 | ||||||||
| LastUpdateDate: | 09/16/2010 | ||||||||
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| AuthorizedOfficialLastName: | FLEMENBAUM | ||||||||
| AuthorizedOfficialFirstName: | ABRAHAM | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 9544319838 | ||||||||
| IsSoleProprietor: | |||||||||
| 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 | 174400000X | ME0025377 | FL | Y | 193400000X SINGLE SPECIALTY GROUP | Other Service Providers | Specialist |
ID Information
| ID | Type | State | Issuer | Description | 0383290500 | 05 | FL | MEDICAID |