Provider Demographics
NPI:1568469823
Name:SOUTH FLORIDA MEDICAL CORP
Entity Type:Organization
Organization Name:SOUTH FLORIDA MEDICAL CORP
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:MRS
Authorized Official - First Name:KAREN
Authorized Official - Middle Name:S
Authorized Official - Last Name:DIETZ
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:561-443-3522
Mailing Address - Street 1:6462 E ROGERS CIR
Mailing Address - Street 2:
Mailing Address - City:BOCA RATON
Mailing Address - State:FL
Mailing Address - Zip Code:33487-2653
Mailing Address - Country:US
Mailing Address - Phone:561-443-3522
Mailing Address - Fax:561-443-3312
Practice Address - Street 1:6462 E ROGERS CIR
Practice Address - Street 2:
Practice Address - City:BOCA RATON
Practice Address - State:FL
Practice Address - Zip Code:33487-2653
Practice Address - Country:US
Practice Address - Phone:561-443-3522
Practice Address - Fax:561-443-3312
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-07-01
Last Update Date:2010-11-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL2003-04453332BX2000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332BX2000XSuppliersDurable Medical Equipment & Medical SuppliesOxygen Equipment & Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLR8660OtherBLUE CROSS BLUE SHIELD
FL952006600Medicaid
FLR8660OtherBLUE CROSS BLUE SHIELD