Provider Demographics
NPI:1205157187
Name:SENIOR CARE MEDICAL CTR
Entity type:Organization
Organization Name:SENIOR CARE MEDICAL CTR
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:COO
Authorized Official - Prefix:
Authorized Official - First Name:ROBERT
Authorized Official - Middle Name:
Authorized Official - Last Name:GORDON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:954-656-8855
Mailing Address - Street 1:2929 N UNIVERSITY DR
Mailing Address - Street 2:SUITE # 110
Mailing Address - City:CORAL SPINGS
Mailing Address - State:FL
Mailing Address - Zip Code:33065-5081
Mailing Address - Country:US
Mailing Address - Phone:954-656-8855
Mailing Address - Fax:954-656-8856
Practice Address - Street 1:9750 NW 33RD STREET
Practice Address - Street 2:SUITE # 212
Practice Address - City:CORAL SPRINGS
Practice Address - State:FL
Practice Address - Zip Code:33065-4042
Practice Address - Country:US
Practice Address - Phone:954-755-5504
Practice Address - Fax:954-755-3414
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-06-15
Last Update Date:2010-06-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME94817207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL40029Medicare PIN