Provider Demographics
NPI:1588849723
Name:PEMBROKE PINES MEDICAL CENTER
Entity Type:Organization
Organization Name:PEMBROKE PINES MEDICAL CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:VICE PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:RICHARD
Authorized Official - Middle Name:A
Authorized Official - Last Name:KOBY
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:305-821-6600
Mailing Address - Street 1:18219 PINES BLVD
Mailing Address - Street 2:
Mailing Address - City:PEMBROKE PINES
Mailing Address - State:FL
Mailing Address - Zip Code:33029-1417
Mailing Address - Country:US
Mailing Address - Phone:954-436-1212
Mailing Address - Fax:954-435-5444
Practice Address - Street 1:18219 PINES BLVD
Practice Address - Street 2:
Practice Address - City:PEMBROKE PINES
Practice Address - State:FL
Practice Address - Zip Code:33029-1417
Practice Address - Country:US
Practice Address - Phone:954-436-1212
Practice Address - Fax:954-435-5444
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-01-07
Last Update Date:2010-03-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME49055207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL014686OtherAVMED KOBY
FL4337911OtherAETNA KOBY
FL265997OtherAVMED ZALIS
FL79162OtherBCBS ZALIS
FL170130OtherHUMANA
FL02704OtherMCR KOBY
FL044892300Medicaid
FL001729OtherNHP ZALIS
FL000901OtherNHP KOBY
FL039823300Medicaid
FL4521008OtherAETNA ZALIS
FL7900000OtherJMH KOBY
FL79162OtherMCR ZALIS
FL02704OtherBCBS KOBY
FL6972300OtherJMH ZALIS
FL79162OtherMCR ZALIS
FL4337911OtherAETNA KOBY
FLD20776Medicare UPIN