Healthcare Provider Details

I. General information

NPI: 1902944382
Provider Name (Legal Business Name): PHOENIX OBSTETRICS AND GYNECOLOGY LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/01/2007
Last Update Date: 05/22/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1600 S ANDREWS AVE
FT LAUDERDALE FL
33316-2510
US

IV. Provider business mailing address

1600 S ANDREWS AVE RPICC SERVICES
FT LAUDERDALE FL
33316-2510
US

V. Phone/Fax

Practice location:
  • Phone: 954-355-5017
  • Fax: 954-714-6335
Mailing address:
  • Phone: 954-355-5017
  • Fax: 919-425-0478

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code174400000X
TaxonomySpecialist
License NumberME43546
License Number StateFL

VIII. Authorized Official

Name: DR. BERTRUM WALLS
Title or Position: PRESIDENT
Credential: M.D.
Phone: 954-355-5017