MEDICARE: FLORIDA MEDICAL AND DIAGNOSTIC CENTER

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	363L00000X	Nurse Practitioner

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	9238727	OTHER	FL	LIC

General Provider Information

NPI Number	:	1942860093
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	FLORIDA MEDICAL AND DIAGNOSTIC CENTER

Provider Business Mailing Address
First Line	:	3020 NE 32ND AVE STE 305
Second Line	:
City	:	FORT LAUDERDALE
State	:	FL
Zip	:	33308-7204
Country	:	US
Telephone Number	:	954-302-3048
Fax Number	:	718-554-1666

Provider Business Practice Location Address
First Line	:	3020 NE 32ND AVE STE 305
Second Line	:
City	:	FORT LAUDERDALE
State	:	FL
Zip	:	33308-7204
Country	:	US
Telephone Number	:	954-302-3048
Fax Number	:	718-554-1666

Authorized Official
Title or Position	:	MEDICAL DIRECTOR
Name	:	MRS. BOGOMOLOVA YULIA
Credential	:
Telephone Number	:	954-302-3048

Provider Enumeration Date	:	06/19/2019
Last Update Date	:	06/19/2019

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