MEDICARE: NICHOLAS D A SUITE MD NEUROLOGY LLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	261QM2500X	Medical Specialty Clinic/Center	ME 59343	FL

General Provider Information

NPI Number	:	1467627208
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	NICHOLAS D A SUITE MD NEUROLOGY LLC

Provider Business Mailing Address
First Line	:	7900 NW 33RD ST STE 101
Second Line	:
City	:	HOLLYWOOD
State	:	FL
Zip	:	33024-2209
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	7900 NW 33RD ST STE 101
Second Line	:
City	:	HOLLYWOOD
State	:	FL
Zip	:	33024-2209
Country	:	US
Telephone Number	:	954-431-6884
Fax Number	:

Authorized Official
Title or Position	:	PRESIDENT
Name	:	NICHOLAS SUITE
Credential	:
Telephone Number	:	954-431-6884

Provider Enumeration Date	:	04/23/2008
Last Update Date	:	04/23/2008

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