Healthcare Provider Details

I. General information

NPI: 1588098669
Provider Name (Legal Business Name): PALM VASCULAR CENTER OF BROWARD, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/26/2013
Last Update Date: 08/26/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3109 STIRLING RD SUITE 100
FORT LAUDERDALE FL
33312-6558
US

IV. Provider business mailing address

3109 STIRLING RD SUITE 100
FORT LAUDERDALE FL
33312-6558
US

V. Phone/Fax

Practice location:
  • Phone: 914-720-3686
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2085R0204X
TaxonomyVascular & Interventional Radiology Physician
License Number
License Number StateFL
# 2
Primary TaxonomyN
Taxonomy Code2086S0129X
TaxonomyVascular Surgery Physician
License Number
License Number StateFL

VIII. Authorized Official

Name: MR. ERIC ROGERS
Title or Position: CEO
Credential:
Phone: 914-720-3686