Provider Demographics
NPI:1942259361
Name:NIDAL RADWAN M.D. PA
Entity Type:Organization
Organization Name:NIDAL RADWAN M.D. PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDNET
Authorized Official - Prefix:
Authorized Official - First Name:NIDAL
Authorized Official - Middle Name:BAZ
Authorized Official - Last Name:RADWAN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:305-948-8900
Mailing Address - Street 1:18100 NE 19TH AVENUE
Mailing Address - Street 2:SUITE #102
Mailing Address - City:NORTH MIAMI BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:33162-1606
Mailing Address - Country:US
Mailing Address - Phone:305-948-8900
Mailing Address - Fax:305-948-3934
Practice Address - Street 1:18100 NE 19TH AVENUE
Practice Address - Street 2:SUITE #102
Practice Address - City:NORTH MIAMI BEACH
Practice Address - State:FL
Practice Address - Zip Code:33162-1606
Practice Address - Country:US
Practice Address - Phone:305-948-8900
Practice Address - Fax:305-948-3934
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-10
Last Update Date:2022-05-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL254331100Medicaid
FL254331100Medicaid
FLE1106Medicare ID - Type Unspecified