Provider Demographics
NPI:1922603422
Name:NOVA SOUTHEASTERN UNIVERSITY, INC
Entity Type:Organization
Organization Name:NOVA SOUTHEASTERN UNIVERSITY, INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CREDENTIALING AND CONTRACTING DIR
Authorized Official - Prefix:
Authorized Official - First Name:ROSEMERY
Authorized Official - Middle Name:
Authorized Official - Last Name:ESTEVEZ
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:954-262-4343
Mailing Address - Street 1:PO BOX 290370
Mailing Address - Street 2:
Mailing Address - City:DAVIE
Mailing Address - State:FL
Mailing Address - Zip Code:33329-0370
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:3625 COLLEGE AVE STE 135
Practice Address - Street 2:
Practice Address - City:DAVIE
Practice Address - State:FL
Practice Address - Zip Code:33314-7724
Practice Address - Country:US
Practice Address - Phone:954-262-4100
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-12-02
Last Update Date:2020-12-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL59-1083502OtherTAX ID