Provider Demographics
NPI:1790905305
Name:CHILDREN'S MEDICAL CENTER, PA.
Entity Type:Organization
Organization Name:CHILDREN'S MEDICAL CENTER, PA.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:THEODORE
Authorized Official - Middle Name:
Authorized Official - Last Name:MORRISON
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:954-989-6000
Mailing Address - Street 1:12251 TAFT ST
Mailing Address - Street 2:
Mailing Address - City:PEMBROKE PINES
Mailing Address - State:FL
Mailing Address - Zip Code:33026-1956
Mailing Address - Country:US
Mailing Address - Phone:954-435-7000
Mailing Address - Fax:954-435-7185
Practice Address - Street 1:12251 TAFT ST
Practice Address - Street 2:
Practice Address - City:PEMBROKE PINES
Practice Address - State:FL
Practice Address - Zip Code:33026-1956
Practice Address - Country:US
Practice Address - Phone:954-435-7000
Practice Address - Fax:954-435-7185
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-26
Last Update Date:2011-09-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME5015302F00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes302F00000XManaged Care OrganizationsExclusive Provider Organization
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL060425901Medicaid