Healthcare Provider Details

I. General information

NPI: 1790087856
Provider Name (Legal Business Name): BLUE LION MEDICAL
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/23/2010
Last Update Date: 11/23/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3600 WASHINGTON ST
HOLLYWOOD FL
33021-8216
US

IV. Provider business mailing address

PO BOX 814479
HOLLYWOOD FL
33081-4479
US

V. Phone/Fax

Practice location:
  • Phone: 954-773-5744
  • Fax: 954-962-1994
Mailing address:
  • Phone: 954-773-5744
  • Fax: 954-962-1994

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363AS0400X
TaxonomySurgical Physician Assistant
License NumberPA9101635
License Number StateFL

VIII. Authorized Official

Name: JEANA MARIE HEINZ
Title or Position: MANAGING DIRECTOR
Credential: PA-C
Phone: 954-557-4140