=====================================================
General NPI Number Information
=====================================================
NPI Number | 1184842395
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | CHILDREN'S MEDICAL CENTER, PA.
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 04/23/2007
-----------------------------------------------------
Last Update Date | 09/19/2011
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 20170 PINES BLVD SUITE 203
-----------------------------------------------------
City | PEMBROKE PINES
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33029-1259
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 954-378-1500
-----------------------------------------------------
Fax | 954-378-1530
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 20170 PINES BLVD SUITE 203
-----------------------------------------------------
City | PEMBROKE PINES
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33029-1259
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 954-378-1500
-----------------------------------------------------
Fax | 954-378-1530
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT
-----------------------------------------------------
Name | THEODORE MORRISON
-----------------------------------------------------
Credential | M.D.
-----------------------------------------------------
Telephone | 954-989-6000
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 302F00000X
-----------------------------------------------------
Taxonomy Name | Exclusive Provider Organization
-----------------------------------------------------
License Number | ME5015
-----------------------------------------------------
License Number State | FL
-----------------------------------------------------