Basic Information
| Provider Information | |||||||||
| NPI: | 1831485093 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | FWC PERINATAL, LLC | ||||||||
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| OtherOrganizationName: | FWC PERINATAL, LLC | ||||||||
| OtherOrganizationType: | 5 | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 5558 | ||||||||
| Address2: | |||||||||
| City: | BELFAST | ||||||||
| State: | ME | ||||||||
| PostalCode: | 049155500 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5613002410 | ||||||||
| FaxNumber: | 5612357292 | ||||||||
| Practice Location | |||||||||
| Address1: | 1501 YAMATO ROAD | ||||||||
| Address2: | SUITE 200 WEST | ||||||||
| City: | BOCA RATON | ||||||||
| State: | FL | ||||||||
| PostalCode: | 33431 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5613002410 | ||||||||
| FaxNumber: | 5612357292 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/24/2011 | ||||||||
| LastUpdateDate: | 02/23/2022 | ||||||||
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| AuthorizedOfficialLastName: | SUDBURY | ||||||||
| AuthorizedOfficialFirstName: | AARON | ||||||||
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| AuthorizedOfficialTitleorPosition: | MEDICAL DIRECTOR | ||||||||
| AuthorizedOfficialTelephone: | 5613002410 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MR. | ||||||||
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| AuthorizedOfficialCredential: | MD | ||||||||
| NPICertificationDate: | 02/23/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207VM0101X | FL | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Obstetrics & Gynecology | Maternal & Fetal Medicine |
No ID Information.