Healthcare Provider Details

I. General information

NPI: 1750390688
Provider Name (Legal Business Name): PMC PLANTATION LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/07/2006
Last Update Date: 09/26/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1806 N PINE ISLAND RD
PLANTATION FL
33322-5202
US

IV. Provider business mailing address

1806 N PINE ISLAND RD
PLANTATION FL
33322-5202
US

V. Phone/Fax

Practice location:
  • Phone: 954-474-0110
  • Fax: 954-424-9859
Mailing address:
  • Phone: 954-474-0110
  • Fax: 954-424-9859

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code173000000X
TaxonomyLegal Medicine
License NumberMC 39723
License Number StateFL

VIII. Authorized Official

Name: MICHAEL J CAVANAUGH
Title or Position: MEDICAL DOCTOR
Credential: MD
Phone: 954-474-0110