Healthcare Provider Details

I. General information

NPI: 1063185825
Provider Name (Legal Business Name): FWC UROGYNECOLOGY, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/28/2021
Last Update Date: 02/23/2022
Certification Date: 02/23/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

770 NORTHPOINT PKWY STE 100
WEST PALM BEACH FL
33407-1901
US

IV. Provider business mailing address

PO BOX 5556
BELFAST ME
04915-5500
US

V. Phone/Fax

Practice location:
  • Phone: 561-655-3331
  • Fax: 561-655-3744
Mailing address:
  • Phone: 561-300-2410
  • Fax: 561-235-7292

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2088F0040X
TaxonomyUrogynecology and Reconstructive Pelvic Surgery (Urology) Physician
License Number
License Number State

VIII. Authorized Official

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