Provider Demographics
NPI:1639347214
Name:PROFESSIONAL HEALTHCARE GROUP, LLC
Entity Type:Organization
Organization Name:PROFESSIONAL HEALTHCARE GROUP, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEDICAL DIRECTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:STEWART
Authorized Official - Middle Name:E
Authorized Official - Last Name:KOPP
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:954-943-8902
Mailing Address - Street 1:150 SW 12TH AVE
Mailing Address - Street 2:SUITE 440
Mailing Address - City:POMPANO BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:33069-3298
Mailing Address - Country:US
Mailing Address - Phone:954-943-8902
Mailing Address - Fax:
Practice Address - Street 1:150 SW 12TH AVE
Practice Address - Street 2:SUITE 440
Practice Address - City:POMPANO BEACH
Practice Address - State:FL
Practice Address - Zip Code:33069-3298
Practice Address - Country:US
Practice Address - Phone:954-943-8902
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-02-15
Last Update Date:2008-02-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLOS3754208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral PracticeGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLE78189Medicare UPIN