Provider Demographics
NPI:1033248190
Name:PCP OF PEMBROKE PINES
Entity Type:Organization
Organization Name:PCP OF PEMBROKE PINES
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:MR
Authorized Official - First Name:PETER
Authorized Official - Middle Name:
Authorized Official - Last Name:ANZALONE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:954-318-6590
Mailing Address - Street 1:1 SW 129TH AVE
Mailing Address - Street 2:SUITE 109
Mailing Address - City:PEMBROKE PINES
Mailing Address - State:FL
Mailing Address - Zip Code:33027-1761
Mailing Address - Country:US
Mailing Address - Phone:954-433-4200
Mailing Address - Fax:
Practice Address - Street 1:1 SW 129TH AVE
Practice Address - Street 2:SUITE 109
Practice Address - City:PEMBROKE PINES
Practice Address - State:FL
Practice Address - Zip Code:33027-1761
Practice Address - Country:US
Practice Address - Phone:954-433-4200
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-05
Last Update Date:2008-04-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL=========OtherCOMMERCIAL INS