Provider Demographics
NPI:1275168650
Name:MEDWIN PA
Entity Type:Organization
Organization Name:MEDWIN PA
Other - Org Name:MEDWIN CLINICIANS
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:MICAH
Authorized Official - Middle Name:BOAZ
Authorized Official - Last Name:EDWIN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:786-214-2001
Mailing Address - Street 1:PO BOX 4067
Mailing Address - Street 2:
Mailing Address - City:FT LAUDERDALE
Mailing Address - State:FL
Mailing Address - Zip Code:33338-4067
Mailing Address - Country:US
Mailing Address - Phone:786-214-2001
Mailing Address - Fax:
Practice Address - Street 1:4850 W OAKLAND PARK BLVD STE 224
Practice Address - Street 2:
Practice Address - City:LAUDERDALE LAKES
Practice Address - State:FL
Practice Address - Zip Code:33313-7261
Practice Address - Country:US
Practice Address - Phone:786-214-2001
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-03-06
Last Update Date:2021-04-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care