Provider Demographics
NPI:1669632105
Name:VARIETY CHILDRENS HOSPITAL
Entity Type:Organization
Organization Name:VARIETY CHILDRENS HOSPITAL
Other - Org Name:MCH RADIOLOGY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:SENIOR VP & CFO
Authorized Official - Prefix:
Authorized Official - First Name:TIMOTHY
Authorized Official - Middle Name:
Authorized Official - Last Name:BIRKENSTOCK
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:305-669-6422
Mailing Address - Street 1:PO BOX 863942
Mailing Address - Street 2:
Mailing Address - City:ORLANDO
Mailing Address - State:FL
Mailing Address - Zip Code:32886-3942
Mailing Address - Country:US
Mailing Address - Phone:305-662-8334
Mailing Address - Fax:
Practice Address - Street 1:3601 NW 107TH AVE
Practice Address - Street 2:
Practice Address - City:DORAL
Practice Address - State:FL
Practice Address - Zip Code:33178-4377
Practice Address - Country:US
Practice Address - Phone:768-624-3675
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:MIAMI CHILDRENS HOSPITAL
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2008-06-09
Last Update Date:2014-10-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2085P0229XAllopathic & Osteopathic PhysiciansRadiologyPediatric RadiologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL256985003Medicaid
FL256985003Medicaid