Healthcare Provider Details

I. General information

NPI: 1285699447
Provider Name (Legal Business Name): JACK A PINES MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/19/2006
Last Update Date: 04/10/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2500 E HALLANDALE BEACH BLVD SUITE PH-2
HALLANDALE BEACH FL
33009-4834
US

IV. Provider business mailing address

2234 COLONIAL BLVD MANAGED CARE DEPT
FORT MYERS FL
33907-1412
US

V. Phone/Fax

Practice location:
  • Phone: 954-456-6500
  • Fax: 954-456-6503
Mailing address:
  • Phone: 239-931-7342
  • Fax: 239-931-7385

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2086X0206X
TaxonomySurgical Oncology Physician
License NumberME 48050
License Number StateFL
# 2
Primary TaxonomyY
Taxonomy Code208800000X
TaxonomyUrology Physician
License NumberME48050
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: