Healthcare Provider Details

I. General information

NPI: 1336983683
Provider Name (Legal Business Name): SHAI JEDIAN
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/21/2024
Last Update Date: 06/21/2024
Certification Date: 06/21/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4725 N FEDERAL HWY
FORT LAUDERDALE FL
33308-4603
US

IV. Provider business mailing address

5800 LAKESHORE DR # 1-208
FORT LAUDERDALE FL
33312-6497
US

V. Phone/Fax

Practice location:
  • Phone: 954-771-8000
  • Fax:
Mailing address:
  • Phone: 310-363-1775
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WC0200X
TaxonomyCritical Care Medicine Registered Nurse
License NumberRN9606190
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: