Provider Demographics
NPI:1346761392
Name:VANGUARD MEDICAL GROUP, LLC
Entity Type:Organization
Organization Name:VANGUARD MEDICAL GROUP, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MD
Authorized Official - Prefix:DR
Authorized Official - First Name:MIAN
Authorized Official - Middle Name:
Authorized Official - Last Name:HASAN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:954-436-6660
Mailing Address - Street 1:603 N FLAMINGO RD STE 150
Mailing Address - Street 2:
Mailing Address - City:PEMBROKE PINES
Mailing Address - State:FL
Mailing Address - Zip Code:33028-1022
Mailing Address - Country:US
Mailing Address - Phone:954-436-6660
Mailing Address - Fax:
Practice Address - Street 1:3401 DAVIE BLVD
Practice Address - Street 2:
Practice Address - City:FORT LAUDERDALE
Practice Address - State:FL
Practice Address - Zip Code:33312-2758
Practice Address - Country:US
Practice Address - Phone:954-436-6660
Practice Address - Fax:954-436-6655
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-06-29
Last Update Date:2017-06-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM1300XAmbulatory Health Care FacilitiesClinic/CenterMulti-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL280980001Medicaid
FL280980000Medicaid