=====================================================
General NPI Number Information
=====================================================
NPI Number | 1134473663
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | FORT LAUDERDALE MEDICAL SURGICAL ASSOCIATES., INC.
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 11/06/2012
-----------------------------------------------------
Last Update Date | 12/07/2012
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2301 WILTON DR SUITE C2
-----------------------------------------------------
City | WILTON MANORS
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33305-1202
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 954-567-5898
-----------------------------------------------------
Fax | 954-567-0395
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2301 WILTON DR SUITE C2
-----------------------------------------------------
City | WILTON MANORS
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33305-1202
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 954-567-5898
-----------------------------------------------------
Fax | 954-567-0395
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | TIMOTHY GOSHEN
-----------------------------------------------------
Credential | DO
-----------------------------------------------------
Telephone | 954-567-5898
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 208C00000X
-----------------------------------------------------
Taxonomy Name | Colon & Rectal Surgery Physician
-----------------------------------------------------
License Number | OS8504
-----------------------------------------------------
License Number State | FL
-----------------------------------------------------