Provider Demographics
NPI:1790087856
Name:BLUE LION MEDICAL
Entity Type:Organization
Organization Name:BLUE LION MEDICAL
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGING DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:JEANA
Authorized Official - Middle Name:MARIE
Authorized Official - Last Name:HEINZ
Authorized Official - Suffix:
Authorized Official - Credentials:PA-C
Authorized Official - Phone:954-557-4140
Mailing Address - Street 1:PO BOX 814479
Mailing Address - Street 2:
Mailing Address - City:HOLLYWOOD
Mailing Address - State:FL
Mailing Address - Zip Code:33081-4479
Mailing Address - Country:US
Mailing Address - Phone:954-773-5744
Mailing Address - Fax:954-962-1994
Practice Address - Street 1:3600 WASHINGTON ST
Practice Address - Street 2:
Practice Address - City:HOLLYWOOD
Practice Address - State:FL
Practice Address - Zip Code:33021-8216
Practice Address - Country:US
Practice Address - Phone:954-773-5744
Practice Address - Fax:954-962-1994
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-11-23
Last Update Date:2010-11-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPA9101635363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgicalGroup - Single Specialty