Healthcare Provider Details

I. General information

NPI: 1487624771
Provider Name (Legal Business Name): SPORTS MEDICINE ASSOCIATES OF SOUTH FLORIDA, P.A.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/26/2006
Last Update Date: 09/24/2024
Certification Date: 09/24/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

220 SW 84TH AVE STE 102
PLANTATION FL
33324-2729
US

IV. Provider business mailing address

220 SW 84TH AVE STE 102
PLANTATION FL
33324-2729
US

V. Phone/Fax

Practice location:
  • Phone: 954-720-1530
  • Fax: 954-720-6540
Mailing address:
  • Phone: 954-349-2345
  • Fax: 954-641-1086

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207XS0106X
TaxonomyOrthopaedic Hand Surgery Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code207XX0005X
TaxonomySports Medicine (Orthopaedic Surgery) Physician
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code208100000X
TaxonomyPhysical Medicine & Rehabilitation Physician
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number
License Number State
# 5
Primary TaxonomyY
Taxonomy Code207X00000X
TaxonomyOrthopaedic Surgery Physician
License Number
License Number State

VIII. Authorized Official

Name: CHRYSTAL A. HERRERA
Title or Position: CREDENTIALING COORDINATOR
Credential:
Phone: 305-218-6965