Basic Information
| Provider Information | |||||||||
| NPI: | 1700924511 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | NOVA SOUTHEASTERN UNIVERSITY, INC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3200 S UNIVERSITY DRIVE | ||||||||
| Address2: | SANFORD L. ZIFF BLDG. 3RD FLOOR, ROOM 4364-D | ||||||||
| City: | FT. LAUDERDALE | ||||||||
| State: | FL | ||||||||
| PostalCode: | 333282018 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9544634217 | ||||||||
| FaxNumber: | 9547643825 | ||||||||
| Practice Location | |||||||||
| Address1: | 650 NORTH ANDREWS AVENUE | ||||||||
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| City: | FT. LAUDERDALE | ||||||||
| State: | FL | ||||||||
| PostalCode: | 333117436 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9542624100 | ||||||||
| FaxNumber: | 9542626888 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/02/2007 | ||||||||
| LastUpdateDate: | 06/16/2011 | ||||||||
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| AuthorizedOfficialLastName: | OLLER | ||||||||
| AuthorizedOfficialFirstName: | ROBERT | ||||||||
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| AuthorizedOfficialTitleorPosition: | CEO/CLINICAL OPERATIONS | ||||||||
| AuthorizedOfficialTelephone: | 9542624343 | ||||||||
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| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | NOVA SOUTHEASTERN UNIVERSITY, INC | ||||||||
| AuthorizedOfficialNamePrefix: | DR. | ||||||||
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| AuthorizedOfficialCredential: | D.O. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 156FX1800X | N | 193200000X MULTI-SPECIALTY GROUP | Eye and Vision Services Providers | Technician/Technologist | Optician | 152W00000X | Y | 193200000X MULTI-SPECIALTY GROUP | Eye and Vision Services Providers | Optometrist |
ID Information
| ID | Type | State | Issuer | Description | 98673A | 01 | FL | MEDICARE GROUP NUMBER | OTHER | 620738300 | 05 | FL | MEDICAID |