Basic Information
| Provider Information | |||||||||
| NPI: | 1578761995 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | NORTH BROWARD HOSPITAL DISTRICT | ||||||||
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| OtherOrganizationName: | BROWARD HEALTH MEDICAL CENTER - PSYCH | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 932540 | ||||||||
| Address2: | |||||||||
| City: | ATLANTA | ||||||||
| State: | GA | ||||||||
| PostalCode: | 311932540 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9548474315 | ||||||||
| FaxNumber: | 9548474270 | ||||||||
| Practice Location | |||||||||
| Address1: | 1600 S ANDREWS AVE | ||||||||
| Address2: | |||||||||
| City: | FORT LAUDERDALE | ||||||||
| State: | FL | ||||||||
| PostalCode: | 333162510 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9543555500 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 07/06/2007 | ||||||||
| LastUpdateDate: | 06/20/2019 | ||||||||
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| AuthorizedOfficialLastName: | SANTORIO | ||||||||
| AuthorizedOfficialFirstName: | GINO | ||||||||
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| AuthorizedOfficialTitleorPosition: | PRESIDENT / CEO | ||||||||
| AuthorizedOfficialTelephone: | 9544737024 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | NORTH BROWARD HOSPITAL DISTRICT | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 273R00000X | 4128 | FL | Y | Hospital Units | Psychiatric Unit |
ID Information
| ID | Type | State | Issuer | Description | 010012901 | 05 | FL | MEDICAID |