Basic Information
Provider Information | |||||||||
NPI: | 1760938724 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | BROWARD HEALTH MEDICAL CENTER | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 1346 SW 3RD CT | ||||||||
Address2: |   | ||||||||
City: | FORT LAUDERDALE | ||||||||
State: | FL | ||||||||
PostalCode: | 333127591 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 3053386233 | ||||||||
FaxNumber: |   | ||||||||
Practice Location | |||||||||
Address1: | 1600 S ANDREWS AVE | ||||||||
Address2: |   | ||||||||
City: | FORT LAUDERDALE | ||||||||
State: | FL | ||||||||
PostalCode: | 333162510 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 9547607172 | ||||||||
FaxNumber: |   | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 08/30/2016 | ||||||||
LastUpdateDate: | 08/30/2016 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | LAI | ||||||||
AuthorizedOfficialFirstName: | ANDERSON | ||||||||
AuthorizedOfficialMiddleName: | KA HO | ||||||||
AuthorizedOfficialTitleorPosition: | PGY1 | ||||||||
AuthorizedOfficialTelephone: | 9292728572 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: | DR. | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: | M.D. | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 282N00000X |   | FL | Y |   | Hospitals | General Acute Care Hospital |   |
No ID Information.