Provider Demographics
NPI:1689733693
Name:SUSSMAN & STALLER MD PA
Entity Type:Organization
Organization Name:SUSSMAN & STALLER MD PA
Other - Org Name:HYGEA SOUTH FLORIDA, INC
Other - Org Type:Other Name
Authorized Official - Title/Position:CHIEF OPERATING OFFICER
Authorized Official - Prefix:
Authorized Official - First Name:DAVID
Authorized Official - Middle Name:
Authorized Official - Last Name:ROMANELLO
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:352-459-3661
Mailing Address - Street 1:150 S PINE ISLAND RD STE 200
Mailing Address - Street 2:
Mailing Address - City:PLANTATION
Mailing Address - State:FL
Mailing Address - Zip Code:33324-2695
Mailing Address - Country:US
Mailing Address - Phone:561-770-2009
Mailing Address - Fax:
Practice Address - Street 1:150 NW 168TH ST STE 301
Practice Address - Street 2:
Practice Address - City:NORTH MIAMI BEACH
Practice Address - State:FL
Practice Address - Zip Code:33169-6051
Practice Address - Country:US
Practice Address - Phone:305-654-5440
Practice Address - Fax:305-654-5445
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-06
Last Update Date:2022-05-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
97500OtherBLUE CROSS BLUE SHIELD
FL258554500Medicaid
97500OtherBLUE CROSS BLUE SHIELD
FL97500BMedicare PIN