Healthcare Provider Details

I. General information

NPI: 1407459985
Provider Name (Legal Business Name): CEREBRAL MEDICAL GROUP, P.A.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/18/2020
Last Update Date: 12/22/2023
Certification Date: 12/22/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1200 S PINE ISLAND RD STE 250
PLANTATION FL
33324-4459
US

IV. Provider business mailing address

2093 PHILADELPHIA PIKE # 9898
CLAYMONT DE
19703-2424
US

V. Phone/Fax

Practice location:
  • Phone: 415-830-5946
  • Fax: 415-651-3458
Mailing address:
  • Phone: 415-830-5946
  • Fax: 415-651-3458

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number
License Number State

VIII. Authorized Official

Name: MICHAEL BOGGS
Title or Position: PRESIDENT
Credential: MD
Phone: 415-830-5946