Basic Information
| Provider Information | |||||||||
| NPI: | 1538188792 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | BRADENTON MEDICAL ENTERPRISES, INC. | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | PHYSICIANS DIALYSIS | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 19559 NE 10TH AVE | ||||||||
| Address2: | |||||||||
| City: | N MIAMI BEACH | ||||||||
| State: | FL | ||||||||
| PostalCode: | 331793501 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3056513261 | ||||||||
| FaxNumber: | 3056512961 | ||||||||
| Practice Location | |||||||||
| Address1: | 4802 GRAND BLVD | ||||||||
| Address2: | |||||||||
| City: | NEW PORT RICHEY | ||||||||
| State: | FL | ||||||||
| PostalCode: | 346525106 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7278158385 | ||||||||
| FaxNumber: | 7278487943 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/19/2006 | ||||||||
| LastUpdateDate: | 05/03/2010 | ||||||||
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| AuthorizedOfficialLastName: | FERNANDEZ | ||||||||
| AuthorizedOfficialFirstName: | ARTURO | ||||||||
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| AuthorizedOfficialTitleorPosition: | VICE PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 3056513261 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 332BD1200X | Y | Suppliers | Durable Medical Equipment & Medical Supplies | Dialysis Equipment & Supplies |
ID Information
| ID | Type | State | Issuer | Description | 209756701 | 05 | FL | MEDICAID | R8226 | 01 | FL | BC BS FLORIDA | OTHER |