Provider Demographics
NPI:1154477214
Name:SOUTHGATE MEDICAL OF FLORIDA, INC.
Entity Type:Organization
Organization Name:SOUTHGATE MEDICAL OF FLORIDA, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:VICE-PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:RICHARD
Authorized Official - Middle Name:EUGENE
Authorized Official - Last Name:STACEY
Authorized Official - Suffix:SR
Authorized Official - Credentials:LNHA
Authorized Official - Phone:305-926-0960
Mailing Address - Street 1:899 NW 4TH ST
Mailing Address - Street 2:
Mailing Address - City:MIAMI
Mailing Address - State:FL
Mailing Address - Zip Code:33128-1309
Mailing Address - Country:US
Mailing Address - Phone:305-926-0960
Mailing Address - Fax:305-326-1647
Practice Address - Street 1:899 NW 4TH ST
Practice Address - Street 2:
Practice Address - City:MIAMI
Practice Address - State:FL
Practice Address - Zip Code:33128-1309
Practice Address - Country:US
Practice Address - Phone:305-926-0960
Practice Address - Fax:305-326-1647
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-25
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL976332BP3500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332BP3500XSuppliersDurable Medical Equipment & Medical SuppliesParenteral & Enteral Nutrition
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL0925670001Medicare ID - Type Unspecified