Healthcare Provider Details

I. General information

NPI: 1114592029
Provider Name (Legal Business Name): FWC UROGYNECOLOGY, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/24/2021
Last Update Date: 02/23/2022
Certification Date: 02/23/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6280 SUNSET DR STE 408
SOUTH MIAMI FL
33143-4860
US

IV. Provider business mailing address

PO BOX 5556
BELFAST ME
04915-5500
US

V. Phone/Fax

Practice location:
  • Phone: 305-441-7999
  • Fax: 305-633-4757
Mailing address:
  • Phone: 561-300-2410
  • Fax: 561-235-7292

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207V00000X
TaxonomyObstetrics & Gynecology Physician
License Number
License Number State
# 2
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: MANAGER
Credential:
Phone: 561-300-2410