Healthcare Provider Details

I. General information

NPI: 1912051228
Provider Name (Legal Business Name): OAKRIDGE MEDICAL GROUP
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/23/2007
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1000 NE 56TH ST ATTN BUSINESS OFFICE
FORT LAUDERDALE FL
33334-4149
US

IV. Provider business mailing address

1000 NE 56TH ST ATTN BUSINESS OFFICE
FORT LAUDERDALE FL
33334-4149
US

V. Phone/Fax

Practice location:
  • Phone: 954-958-0606
  • Fax: 954-776-0821
Mailing address:
  • Phone: 954-958-0606
  • Fax: 954-776-0821

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code247100000X
TaxonomyRadiologic Technologist
License NumberJR3583900
License Number StateFL

VIII. Authorized Official

Name: MR. FRITZ PHANORD
Title or Position: BUSINESS OFFICE MANAGER
Credential:
Phone: 954-958-0606