Provider Demographics
NPI:1619015658
Name:SOUTH BROWARD SURGICAL GROUP LLC
Entity Type:Organization
Organization Name:SOUTH BROWARD SURGICAL GROUP LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGING PARTNER
Authorized Official - Prefix:DR
Authorized Official - First Name:DEXTER
Authorized Official - Middle Name:C
Authorized Official - Last Name:SEREDA
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:954-447-4480
Mailing Address - Street 1:PO BOX 260939
Mailing Address - Street 2:
Mailing Address - City:PEMBROKE PINES
Mailing Address - State:FL
Mailing Address - Zip Code:33026-7939
Mailing Address - Country:US
Mailing Address - Phone:954-447-4480
Mailing Address - Fax:954-447-5344
Practice Address - Street 1:601 N FLAMINGO RD
Practice Address - Street 2:SUITE 211
Practice Address - City:PEMBROKE PINES
Practice Address - State:FL
Practice Address - Zip Code:33028-1015
Practice Address - Country:US
Practice Address - Phone:954-447-4480
Practice Address - Fax:954-447-5344
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-02
Last Update Date:2008-10-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL270575300Medicaid
FL=========OtherTAX ID
H09315Medicare UPIN
H28418Medicare UPIN
FL=========OtherTAX ID
FL270575300Medicaid