Basic Information
| Provider Information | |||||||||
| NPI: | 1538553821 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | SOUTH FLORIDA GERIATRIC MEDICINE PA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 529 MAJORCA AVE | ||||||||
| Address2: | |||||||||
| City: | CORAL GABLES | ||||||||
| State: | FL | ||||||||
| PostalCode: | 331344221 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7867096162 | ||||||||
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| Practice Location | |||||||||
| Address1: | 3200 S UNIVERSITY DR | ||||||||
| Address2: | SANDFORD L. ZIFF BLDG | ||||||||
| City: | DAVIE | ||||||||
| State: | FL | ||||||||
| PostalCode: | 333282018 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9542624100 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 03/24/2015 | ||||||||
| LastUpdateDate: | 03/24/2015 | ||||||||
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| AuthorizedOfficialLastName: | ALMASRI | ||||||||
| AuthorizedOfficialFirstName: | HADY | ||||||||
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| AuthorizedOfficialTitleorPosition: | OWNER | ||||||||
| AuthorizedOfficialTelephone: | 7867096162 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | DR. | ||||||||
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| AuthorizedOfficialCredential: | DO | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | OS10363 | FL | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | CO392Z | 01 | FL | MEDICARE PTAN NUMBER | OTHER | 002276300 | 05 | FL | MEDICAID |