Basic Information
| Provider Information | |||||||||
| NPI: | 1811401805 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | CCG PALLIATIVE CARE SERVICES, LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 8251 W BROWARD BLVD STE 103 | ||||||||
| Address2: | |||||||||
| City: | PLANTATION | ||||||||
| State: | FL | ||||||||
| PostalCode: | 333242703 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9542557310 | ||||||||
| FaxNumber: | 9542557311 | ||||||||
| Practice Location | |||||||||
| Address1: | 8251 W BROWARD BLVD STE 103 | ||||||||
| Address2: | |||||||||
| City: | PLANTATION | ||||||||
| State: | FL | ||||||||
| PostalCode: | 333242703 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9542557310 | ||||||||
| FaxNumber: | 9542557311 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/29/2017 | ||||||||
| LastUpdateDate: | 03/17/2018 | ||||||||
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| AuthorizedOfficialLastName: | PEREIRA | ||||||||
| AuthorizedOfficialFirstName: | MARIO | ||||||||
| AuthorizedOfficialMiddleName: | B | ||||||||
| AuthorizedOfficialTitleorPosition: | MD | ||||||||
| AuthorizedOfficialTelephone: | 9542557310 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | DR. | ||||||||
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| AuthorizedOfficialCredential: | MD | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | ME104716 | FL | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine |
No ID Information.