Healthcare Provider Details

I. General information

NPI: 1588377949
Provider Name (Legal Business Name): ADVANCED MEDICAL PROVIDER INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/02/2023
Last Update Date: 01/02/2023
Certification Date: 12/21/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1560 SAWGRASS CORPORATE PKWY FL 4
SUNRISE FL
33323-2855
US

IV. Provider business mailing address

11510 SW 2ND ST
PLANTATION FL
33325-2922
US

V. Phone/Fax

Practice location:
  • Phone: 954-600-8994
  • Fax:
Mailing address:
  • Phone: 954-600-8994
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code171000000X
TaxonomyMilitary Health Care Provider
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code261Q00000X
TaxonomyClinic/Center
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code302F00000X
TaxonomyExclusive Provider Organization
License Number
License Number State

VIII. Authorized Official

Name: MS. JESSY MADHUKAR
Title or Position: PRESIDENT
Credential: NP
Phone: 954-600-8994