MEDICARE: MEDICAL REHAB CLINIC OF BROWARD 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	207Q00000X	Family Medicine Physician	OS8590	FL

Medicare Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
2	U2206X	OTHER		MEDICARE PTAN

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
3	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1891703351
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	MEDICAL REHAB CLINIC OF BROWARD LLC

Provider Business Mailing Address
First Line	:	1528 NE 4TH AVE
Second Line	:
City	:	FORT LAUDERDALE
State	:	FL
Zip	:	33304-1036
Country	:	US
Telephone Number	:	954-467-8855
Fax Number	:	954-467-8857

Provider Business Practice Location Address
First Line	:	1528 NE 4TH AVE
Second Line	:
City	:	FORT LAUDERDALE
State	:	FL
Zip	:	33304-1036
Country	:	US
Telephone Number	:	954-467-8855
Fax Number	:	954-467-8857

Authorized Official
Title or Position	:	MEDICAL DIRECTOR
Name	:	CHARLES HARRY RICHARD
Credential	:	D.O.
Telephone Number	:	954-467-8855

Provider Enumeration Date	:	08/03/2006
Last Update Date	:	11/19/2012

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