Provider Demographics
NPI:1689742157
Name:SOUTH FLORIDA CENTER OF GASTROENTEROLOGY
Entity Type:Organization
Organization Name:SOUTH FLORIDA CENTER OF GASTROENTEROLOGY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:MATTHEW
Authorized Official - Middle Name:J
Authorized Official - Last Name:SMITH
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:561-798-2425
Mailing Address - Street 1:10115 W FOREST HILL BLVD
Mailing Address - Street 2:SUITE 100
Mailing Address - City:WELLINGTON
Mailing Address - State:FL
Mailing Address - Zip Code:33414-3105
Mailing Address - Country:US
Mailing Address - Phone:561-798-2425
Mailing Address - Fax:561-798-6356
Practice Address - Street 1:10115 W FOREST HILL BLVD
Practice Address - Street 2:SUITE 100
Practice Address - City:WELLINGTON
Practice Address - State:FL
Practice Address - Zip Code:33414-3105
Practice Address - Country:US
Practice Address - Phone:561-798-2425
Practice Address - Fax:561-798-6356
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-01
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLOS4502207RG0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RG0100XAllopathic & Osteopathic PhysiciansInternal MedicineGastroenterologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLE12169Medicare UPIN
FL80041ZMedicare ID - Type UnspecifiedMCR PROVIDER NUMBER