Provider Demographics
NPI:1568411700
Name:PHOENIX OBSTERICS/GYNECOLOGY, LLC
Entity Type:Organization
Organization Name:PHOENIX OBSTERICS/GYNECOLOGY, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:BERTRAM
Authorized Official - Middle Name:
Authorized Official - Last Name:WALLS
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:954-838-2371
Mailing Address - Street 1:3114 CROASDAILE DR STE 200
Mailing Address - Street 2:PHOENIX OBSTETRICS/GYNECOLOGY, LLC
Mailing Address - City:DURHAM
Mailing Address - State:NC
Mailing Address - Zip Code:27705-2508
Mailing Address - Country:US
Mailing Address - Phone:919-425-1565
Mailing Address - Fax:919-425-0478
Practice Address - Street 1:500 SE 17TH ST
Practice Address - Street 2:SUITE 100
Practice Address - City:FT LAUDERDALE
Practice Address - State:FL
Practice Address - Zip Code:33316-2547
Practice Address - Country:US
Practice Address - Phone:919-425-1565
Practice Address - Fax:919-425-0478
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-06
Last Update Date:2019-08-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME43546207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL269096903Medicaid
FLK7041Medicare PIN