Healthcare Provider Details

I. General information

NPI: 1457026429
Provider Name (Legal Business Name): FWC UROGYNECOOLOGY, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/12/2021
Last Update Date: 09/22/2021
Certification Date: 09/22/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2300 S CONGRESS AVE STE 104
BOYNTON BEACH FL
33426-7400
US

IV. Provider business mailing address

PO BOX 5556
BELFAST ME
04915-5500
US

V. Phone/Fax

Practice location:
  • Phone: 561-752-0893
  • Fax: 561-752-3224
Mailing address:
  • Phone: 561-300-2410
  • Fax: 561-235-7292

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2088F0040X
TaxonomyUrogynecology and Reconstructive Pelvic Surgery (Urology) Physician
License Number
License Number State

VIII. Authorized Official

Name: ERICA HERNANDEZ
Title or Position: MANAGER
Credential:
Phone: 561-300-2410