Basic Information
| Provider Information | |||||||||
| NPI: | 1700074226 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | DIGESTIVE DISEASES SERVICES OF SOUTH FLORIDA P A | ||||||||
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| Mailing Information | |||||||||
| Address1: | 5501 W 79TH ST | ||||||||
| Address2: | SUITE 400 | ||||||||
| City: | BURBANK | ||||||||
| State: | IL | ||||||||
| PostalCode: | 604591784 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7738844523 | ||||||||
| FaxNumber: | 7738844580 | ||||||||
| Practice Location | |||||||||
| Address1: | 777 E 25TH ST | ||||||||
| Address2: | SUITE 416 | ||||||||
| City: | HIALEAH | ||||||||
| State: | FL | ||||||||
| PostalCode: | 330133825 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7864931551 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 10/10/2007 | ||||||||
| LastUpdateDate: | 10/21/2014 | ||||||||
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| AuthorizedOfficialLastName: | NASIFF | ||||||||
| AuthorizedOfficialFirstName: | LUIS | ||||||||
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| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 7864931551 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | M.D. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207RG0100X | ME57104 | FL | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine | Gastroenterology |
ID Information
| ID | Type | State | Issuer | Description | ME57104 | 01 | FL | LICENSE | OTHER |