Healthcare Provider Details

I. General information

NPI: 1578778627
Provider Name (Legal Business Name): PHYSICIAN OFFICES OF FLORIDA CITY
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/11/2007
Last Update Date: 05/04/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

646 WEST PALM DRIVE
FLORIDA CITY FL
33034
US

IV. Provider business mailing address

646 WEST PALM DRIVE
FLORIDA CITY FL
33034
US

V. Phone/Fax

Practice location:
  • Phone: 305-242-0883
  • Fax: 305-242-9523
Mailing address:
  • Phone: 305-242-0883
  • Fax: 305-242-9523

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2080A0000X
TaxonomyPediatric Adolescent Medicine Physician
License Number0062068
License Number StateFL

VIII. Authorized Official

Name: IRA S WELLISCH
Title or Position: VICE PRESIDENT
Credential:
Phone: 305-254-8875