Provider Demographics
NPI:1942860093
Name:FLORIDA MEDICAL AND DIAGNOSTIC CENTER
Entity Type:Organization
Organization Name:FLORIDA MEDICAL AND DIAGNOSTIC CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEDICAL DIRECTOR
Authorized Official - Prefix:MRS
Authorized Official - First Name:BOGOMOLOVA
Authorized Official - Middle Name:
Authorized Official - Last Name:YULIA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:954-302-3048
Mailing Address - Street 1:3020 NE 32ND AVE STE 305
Mailing Address - Street 2:
Mailing Address - City:FORT LAUDERDALE
Mailing Address - State:FL
Mailing Address - Zip Code:33308-7204
Mailing Address - Country:US
Mailing Address - Phone:954-302-3048
Mailing Address - Fax:718-554-1666
Practice Address - Street 1:3020 NE 32ND AVE STE 305
Practice Address - Street 2:
Practice Address - City:FORT LAUDERDALE
Practice Address - State:FL
Practice Address - Zip Code:33308-7204
Practice Address - Country:US
Practice Address - Phone:954-302-3048
Practice Address - Fax:718-554-1666
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-06-19
Last Update Date:2019-06-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL9238727OtherLIC