Healthcare Provider Details

I. General information

NPI: 1194564666
Provider Name (Legal Business Name): FWC UROGYNECOOLOGY, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/23/2024
Last Update Date: 05/30/2024
Certification Date: 05/30/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

621 SE PORT ST LUCIE BLVD # 621-B
PORT SAINT LUCIE FL
34984-5141
US

IV. Provider business mailing address

PO BOX 9100
BELFAST ME
04915-9100
US

V. Phone/Fax

Practice location:
  • Phone: 561-626-3800
  • Fax: 561-624-6364
Mailing address:
  • Phone: 561-300-2410
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207VF0040X
TaxonomyUrogynecology and Reconstructive Pelvic Surgery (Obstetrics & Gynecology) Physician
License Number
License Number State

VIII. Authorized Official

Name: ERICA HERNANDEZ
Title or Position: DIRECTOR
Credential:
Phone: 561-300-2410