Provider Demographics
NPI:1134473663
Name:FORT LAUDERDALE MEDICAL SURGICAL ASSOCIATES., INC.
Entity Type:Organization
Organization Name:FORT LAUDERDALE MEDICAL SURGICAL ASSOCIATES., INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:TIMOTHY
Authorized Official - Middle Name:
Authorized Official - Last Name:GOSHEN
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:954-567-5898
Mailing Address - Street 1:2301 WILTON DR
Mailing Address - Street 2:SUITE C2
Mailing Address - City:WILTON MANORS
Mailing Address - State:FL
Mailing Address - Zip Code:33305-1202
Mailing Address - Country:US
Mailing Address - Phone:954-567-5898
Mailing Address - Fax:954-567-0395
Practice Address - Street 1:2301 WILTON DR
Practice Address - Street 2:SUITE C2
Practice Address - City:WILTON MANORS
Practice Address - State:FL
Practice Address - Zip Code:33305-1202
Practice Address - Country:US
Practice Address - Phone:954-567-5898
Practice Address - Fax:954-567-0395
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-11-06
Last Update Date:2012-12-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLOS8504208C00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208C00000XAllopathic & Osteopathic PhysiciansColon & Rectal SurgeryGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL266516600Medicaid
57739OtherMEDICARE
FL266516600Medicaid