Basic Information
| Provider Information | |||||||||
| NPI: | 1992771422 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | SOUTH FLORIDA CENTER OF GASTROENTEROLOGY | ||||||||
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| Mailing Information | |||||||||
| Address1: | 10115 FOREST HILL BLVD | ||||||||
| Address2: | SUITE 100 | ||||||||
| City: | WELLINGTON | ||||||||
| State: | FL | ||||||||
| PostalCode: | 33414 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5617982425 | ||||||||
| FaxNumber: | 5617986356 | ||||||||
| Practice Location | |||||||||
| Address1: | 10115 FOREST HILL BLVD | ||||||||
| Address2: | SUITE 100 | ||||||||
| City: | WELLINGTON | ||||||||
| State: | FL | ||||||||
| PostalCode: | 33414 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5617982425 | ||||||||
| FaxNumber: | 5617986356 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/24/2006 | ||||||||
| LastUpdateDate: | 07/30/2008 | ||||||||
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| AuthorizedOfficialLastName: | SMITH | ||||||||
| AuthorizedOfficialFirstName: | MATTHEW | ||||||||
| AuthorizedOfficialMiddleName: | J | ||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 5617982425 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | DR. | ||||||||
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| AuthorizedOfficialCredential: | DO | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207RG0100X | 05-5402 | FL | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine | Gastroenterology |
ID Information
| ID | Type | State | Issuer | Description | BS3749489 | 01 | FL | SACKS DEA | OTHER | 057313200 | 05 | FL | MEDICAID | AS2909793 | 01 | FL | SMITH DEA | OTHER | BD0116120 | 01 | FL | DAVIS DEA | OTHER |