Provider Demographics
NPI:1376723478
Name:MICHAEL FISH PHD PA
Entity Type:Organization
Organization Name:MICHAEL FISH PHD PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT/PSYCHOLOGIST
Authorized Official - Prefix:DR
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:
Authorized Official - Last Name:FISH
Authorized Official - Suffix:
Authorized Official - Credentials:PHD
Authorized Official - Phone:954-370-7692
Mailing Address - Street 1:1304 SW 160TH AVE
Mailing Address - Street 2:SUITE 339
Mailing Address - City:SUNRISE
Mailing Address - State:FL
Mailing Address - Zip Code:33326-1902
Mailing Address - Country:US
Mailing Address - Phone:954-370-7692
Mailing Address - Fax:954-370-2383
Practice Address - Street 1:10200 W STATE ROAD 84 STE 105
Practice Address - Street 2:
Practice Address - City:DAVIE
Practice Address - State:FL
Practice Address - Zip Code:33324-4218
Practice Address - Country:US
Practice Address - Phone:954-370-7692
Practice Address - Fax:954-370-2383
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-11-06
Last Update Date:2017-10-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPY3726103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL73683OtherBLUE CROSS/BLUE SHIELD
FL056610OtherVALUE OPTIONS/TRICARE
FLK9104Medicare UPIN