Provider Demographics
NPI:1083016653
Name:VERSANT MEDICAL CENTER
Entity Type:Organization
Organization Name:VERSANT MEDICAL CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:JOHNY
Authorized Official - Middle Name:
Authorized Official - Last Name:HAWKINS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:786-479-3305
Mailing Address - Street 1:10404 WEST FLAGLER ST STE 15
Mailing Address - Street 2:
Mailing Address - City:MIAMI
Mailing Address - State:FL
Mailing Address - Zip Code:33174
Mailing Address - Country:US
Mailing Address - Phone:786-479-3305
Mailing Address - Fax:
Practice Address - Street 1:10404 WEST FLAGLER ST STE 15
Practice Address - Street 2:
Practice Address - City:MIAMI
Practice Address - State:FL
Practice Address - Zip Code:33174
Practice Address - Country:US
Practice Address - Phone:786-479-3305
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-09-25
Last Update Date:2014-09-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes302R00000XManaged Care OrganizationsHealth Maintenance Organization