Provider Demographics
NPI:1578778627
Name:PHYSICIAN OFFICES OF FLORIDA CITY
Entity Type:Organization
Organization Name:PHYSICIAN OFFICES OF FLORIDA CITY
Other - Org Name:PHYSICIAN OFFICES OF FLORIDA CITY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:VICE PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:IRA
Authorized Official - Middle Name:S
Authorized Official - Last Name:WELLISCH
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:305-254-8875
Mailing Address - Street 1:646 WEST PALM DRIVE
Mailing Address - Street 2:
Mailing Address - City:FLORIDA CITY
Mailing Address - State:FL
Mailing Address - Zip Code:33034
Mailing Address - Country:US
Mailing Address - Phone:305-242-0883
Mailing Address - Fax:305-242-9523
Practice Address - Street 1:646 WEST PALM DRIVE
Practice Address - Street 2:
Practice Address - City:FLORIDA CITY
Practice Address - State:FL
Practice Address - Zip Code:33034
Practice Address - Country:US
Practice Address - Phone:305-242-0883
Practice Address - Fax:305-242-9523
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-11
Last Update Date:2011-05-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL00620682080A0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2080A0000XAllopathic & Osteopathic PhysiciansPediatricsAdolescent MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL375969500Medicaid