Provider Demographics
NPI:1679681449
Name:SUNLIFE OB-GYN SERVICES OF FT LAUDERDALE PA
Entity Type:Organization
Organization Name:SUNLIFE OB-GYN SERVICES OF FT LAUDERDALE PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:WINSTON
Authorized Official - Middle Name:O
Authorized Official - Last Name:BLISS
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:954-522-2979
Mailing Address - Street 1:PO BOX 945953
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30394-5953
Mailing Address - Country:US
Mailing Address - Phone:954-522-2979
Mailing Address - Fax:954-903-0633
Practice Address - Street 1:4101 NW 4TH ST
Practice Address - Street 2:SUITE 306
Practice Address - City:PLANTATION
Practice Address - State:FL
Practice Address - Zip Code:33317-2840
Practice Address - Country:US
Practice Address - Phone:954-522-2979
Practice Address - Fax:954-903-0633
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-29
Last Update Date:2012-07-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME71138207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL276564100Medicaid
FL32290Medicare PIN