Provider Demographics
NPI:1174656599
Name:MINIMALLY INVASIVE SURGERY INC
Entity Type:Organization
Organization Name:MINIMALLY INVASIVE SURGERY INC
Other - Org Name:MINIMALLY INVASIVE SURGERY INC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:SURGEON
Authorized Official - Prefix:DR
Authorized Official - First Name:RONALD
Authorized Official - Middle Name:E
Authorized Official - Last Name:MOORE
Authorized Official - Suffix:JR
Authorized Official - Credentials:MD
Authorized Official - Phone:954-797-4220
Mailing Address - Street 1:4101 N.W. 4TH STREET
Mailing Address - Street 2:SUITE 401
Mailing Address - City:PLANTATION
Mailing Address - State:FL
Mailing Address - Zip Code:33317-2813
Mailing Address - Country:US
Mailing Address - Phone:954-797-4220
Mailing Address - Fax:954-797-4221
Practice Address - Street 1:4101 N.W. 4TH STREET
Practice Address - Street 2:SUITE 401
Practice Address - City:PLANTATION
Practice Address - State:FL
Practice Address - Zip Code:33317-2813
Practice Address - Country:US
Practice Address - Phone:954-797-4220
Practice Address - Fax:954-797-4221
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-14
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL274253500Medicaid
FL71634OtherBCBS
FL274253500Medicaid