Basic Information
| Provider Information | |||||||||
| NPI: | 1720126584 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | NOVA SOUTHEASTERN UNIVERSITY, INC. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3200 S UNIVERSITY DR | ||||||||
| Address2: | SANFORD L. ZIFF BLDG, 3RD FLOOR, ROOM 4364-D | ||||||||
| City: | FORT LAUDERDALE | ||||||||
| State: | FL | ||||||||
| PostalCode: | 333282018 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9542624343 | ||||||||
| FaxNumber: | 9542621172 | ||||||||
| Practice Location | |||||||||
| Address1: | 3301 COLLEGE AVE | ||||||||
| Address2: | UNIVERSITY CENTER ROOM 1433 | ||||||||
| City: | FT. LAUDERDALE | ||||||||
| State: | FL | ||||||||
| PostalCode: | 333147721 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9542625590 | ||||||||
| FaxNumber: | 9542625570 | ||||||||
| 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. | ||||||||
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| AuthorizedOfficialCredential: | D.O. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 204D00000X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Neuromusculoskeletal Medicine & OMM | 207QS0010X | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Family Medicine | Sports Medicine |
ID Information
| ID | Type | State | Issuer | Description | 062133100 | 05 | FL | MEDICAID | 98673 | 01 | FL | MEDICARE GROUP NUMBER | OTHER |