Healthcare Provider Details

I. General information

NPI: 1417906561
Provider Name (Legal Business Name): PREMIERE PERINATAL ASSOCIATES
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/08/2006
Last Update Date: 09/17/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

200 NW 7TH AVE PREMIERE PERINATAL ASSOCIATES
FT LAUDERDALE FL
33311-9026
US

IV. Provider business mailing address

500 SE 17TH ST SUITE 100
FT LAUDERDALE FL
33316-2547
US

V. Phone/Fax

Practice location:
  • Phone: 954-759-6789
  • Fax: 919-425-0478
Mailing address:
  • Phone: 919-425-1565
  • Fax: 919-425-0478

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207VM0101X
TaxonomyMaternal & Fetal Medicine Physician
License NumberME43546
License Number StateFL

VIII. Authorized Official

Name: DR. BERTRAM WALLS
Title or Position: OWNER/PRESIDENT
Credential: MD
Phone: 954-838-2371