Provider Demographics
NPI:1093025231
Name:VAN BUREN MEDICAL CENTER, INC.
Entity Type:Organization
Organization Name:VAN BUREN MEDICAL CENTER, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:ALIX
Authorized Official - Middle Name:
Authorized Official - Last Name:GAY
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:954-921-7533
Mailing Address - Street 1:2600 VAN BUREN ST
Mailing Address - Street 2:
Mailing Address - City:HOLLYWOOD
Mailing Address - State:FL
Mailing Address - Zip Code:33020-4818
Mailing Address - Country:US
Mailing Address - Phone:954-921-7533
Mailing Address - Fax:954-921-7505
Practice Address - Street 1:2600 VAN BUREN ST
Practice Address - Street 2:
Practice Address - City:HOLLYWOOD
Practice Address - State:FL
Practice Address - Zip Code:33020-4818
Practice Address - Country:US
Practice Address - Phone:954-921-7533
Practice Address - Fax:954-921-7505
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-10-20
Last Update Date:2010-10-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL54112261QP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL08224BMedicare PIN