Healthcare Provider Details

I. General information

NPI: 1750677019
Provider Name (Legal Business Name): FWC GYN ONCOLOGY, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/24/2011
Last Update Date: 05/17/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1501 YAMATO ROAD SUITE 200 WEST
BOCA RATON FL
33431
US

IV. Provider business mailing address

PO BOX 5555
BELFAST ME
04915-5500
US

V. Phone/Fax

Practice location:
  • Phone: 561-300-2410
  • Fax: 561-235-7292
Mailing address:
  • Phone: 561-300-2410
  • Fax: 561-235-7292

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207VX0201X
TaxonomyGynecologic Oncology Physician
License Number
License Number State

VIII. Authorized Official

Name: MR. AARON SUDBURY
Title or Position: MEDICAL DIRECTOR
Credential: MD
Phone: 561-300-2410