Provider Demographics
NPI:1083910632
Name:SURAMED HEALTH CENTER PA
Entity Type:Organization
Organization Name:SURAMED HEALTH CENTER PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PEDIATRICIAN
Authorized Official - Prefix:DR
Authorized Official - First Name:ALFONSO
Authorized Official - Middle Name:J
Authorized Official - Last Name:HENRIQUEZ
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:561-275-7100
Mailing Address - Street 1:3255 FOREST HILL BLVD STE 107
Mailing Address - Street 2:
Mailing Address - City:WEST PALM BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:33406-5854
Mailing Address - Country:US
Mailing Address - Phone:561-275-7100
Mailing Address - Fax:561-275-7199
Practice Address - Street 1:3255 FOREST HILL BLVD
Practice Address - Street 2:SUITE 107
Practice Address - City:WEST PALM BEACH
Practice Address - State:FL
Practice Address - Zip Code:33406-5854
Practice Address - Country:US
Practice Address - Phone:561-275-7100
Practice Address - Fax:561-275-7167
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-01-31
Last Update Date:2022-04-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME98652208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL255695200Medicaid
FL255695200Medicaid