Provider Demographics
NPI:1609898683
Name:ST. GEORGE SPINAL CLINIC PA
Entity Type:Organization
Organization Name:ST. GEORGE SPINAL CLINIC PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICIAN
Authorized Official - Prefix:DR
Authorized Official - First Name:WAGDY
Authorized Official - Middle Name:B
Authorized Official - Last Name:TADROS
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:954-486-1966
Mailing Address - Street 1:PO BOX 10693
Mailing Address - Street 2:
Mailing Address - City:RIVIERA BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:33419-0693
Mailing Address - Country:US
Mailing Address - Phone:954-486-1966
Mailing Address - Fax:954-486-9115
Practice Address - Street 1:4469 N STATE ROAD 7
Practice Address - Street 2:
Practice Address - City:LAUDERDALE LAKES
Practice Address - State:FL
Practice Address - Zip Code:33319-5876
Practice Address - Country:US
Practice Address - Phone:954-486-1966
Practice Address - Fax:954-486-9115
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-25
Last Update Date:2011-08-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME65248207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL2621902OtherAETNA
FL25940OtherBCBS ID
FL234955OtherAVMED
FL2621902OtherAETNA
FLK6593Medicare ID - Type UnspecifiedGROUP IDENTIFICATION NUM