Healthcare Provider Details

I. General information

NPI: 1861815177
Provider Name (Legal Business Name): 40TH STREET INPATIENT SERVICES, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/23/2014
Last Update Date: 12/05/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11750 SW 40TH ST
MIAMI FL
33175
US

IV. Provider business mailing address

PO BOX 37997
PHILADELPHIA PA
19101-0597
US

V. Phone/Fax

Practice location:
  • Phone: 305-223-3000
  • Fax:
Mailing address:
  • Phone: 973-251-1132
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number
License Number State

VIII. Authorized Official

Name: KATHY KONDAS
Title or Position: OFFICER
Credential:
Phone: 973-251-1132