Basic Information
| Provider Information | |||||||||
| NPI: | 1649456997 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | NORTH BROWARD HOSPITAL DISTRICT | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | BH PHYSICIANS MAIN | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1700 NW 49TH ST STE 125 | ||||||||
| Address2: | |||||||||
| City: | FORT LAUDERDALE | ||||||||
| State: | FL | ||||||||
| PostalCode: | 333093763 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9547126427 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 1625 SE 3RD AVE STE 623 | ||||||||
| Address2: | |||||||||
| City: | FORT LAUDERDALE | ||||||||
| State: | FL | ||||||||
| PostalCode: | 333162521 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9547126427 | ||||||||
| FaxNumber: | 9547126475 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/17/2008 | ||||||||
| LastUpdateDate: | 08/22/2022 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | FERNANDEZ | ||||||||
| AuthorizedOfficialFirstName: | ALEXANDER | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | SVP/CFO | ||||||||
| AuthorizedOfficialTelephone: | 9544737315 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | NORTH BROWARD HOSPITAL DISTRICT | ||||||||
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| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 08/22/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207RI0200X | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine | Infectious Disease |
ID Information
| ID | Type | State | Issuer | Description | 00020 | 01 | FL | BCBS | OTHER | 253794034 | 05 | FL | MEDICAID |