Provider Demographics
NPI:1780649194
Name:NOVA SOUTHEASTERN UNIVERSITY, INC.
Entity Type:Organization
Organization Name:NOVA SOUTHEASTERN UNIVERSITY, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:ROBERT
Authorized Official - Middle Name:S
Authorized Official - Last Name:OLLER
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:954-262-4399
Mailing Address - Street 1:3200 S UNIVERSITY DR
Mailing Address - Street 2:ASSEMBLY BUILDING II, SUITE 202
Mailing Address - City:DAVIE
Mailing Address - State:FL
Mailing Address - Zip Code:33328-2018
Mailing Address - Country:US
Mailing Address - Phone:954-262-4399
Mailing Address - Fax:954-262-1172
Practice Address - Street 1:3200 S UNIVERSITY DR
Practice Address - Street 2:ASSEMBLY BUILDING II, SUITE 202
Practice Address - City:DAVIE
Practice Address - State:FL
Practice Address - Zip Code:33328-2018
Practice Address - Country:US
Practice Address - Phone:954-262-4399
Practice Address - Fax:954-262-1172
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-04-19
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLOS2443207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLOS 2443OtherMEDICAL LICENSE