Provider Demographics
NPI:1912113523
Name:COLON AND RECTAL CLINIC OF FORT LAUDERDALE PA
Entity Type:Organization
Organization Name:COLON AND RECTAL CLINIC OF FORT LAUDERDALE PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:CHARLES
Authorized Official - Middle Name:PETER
Authorized Official - Last Name:LAGO
Authorized Official - Suffix:SR
Authorized Official - Credentials:MD
Authorized Official - Phone:954-236-5444
Mailing Address - Street 1:PO BOX 15466
Mailing Address - Street 2:
Mailing Address - City:PLANTATION
Mailing Address - State:FL
Mailing Address - Zip Code:33318-5466
Mailing Address - Country:US
Mailing Address - Phone:954-236-5444
Mailing Address - Fax:954-236-5422
Practice Address - Street 1:350 N PINE ISLAND RD
Practice Address - Street 2:SUITE 300
Practice Address - City:PLANTATION
Practice Address - State:FL
Practice Address - Zip Code:33324-1849
Practice Address - Country:US
Practice Address - Phone:954-236-5444
Practice Address - Fax:954-236-5422
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-14
Last Update Date:2010-06-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208C00000XAllopathic & Osteopathic PhysiciansColon & Rectal SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL7149530OtherAETNA PPO
FLP00068580OtherMEDICARE RAILROAD
FL1380688OtherUNITED HEALTHCARE
FL3423310OtherAETNA HMO
FLK5322Medicare PIN