=====================================================
General NPI Number Information
=====================================================
NPI Number | 1346859741
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | ANDERSON MEDICAL SERVICES LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/31/2020
-----------------------------------------------------
Last Update Date | 12/05/2024
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 805 E BROWARD BLVD STE 301
-----------------------------------------------------
City | FORT LAUDERDALE
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33301-2046
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 954-994-1312
-----------------------------------------------------
Fax | 954-466-3888
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 805 E BROWARD BLVD STE 301
-----------------------------------------------------
City | FORT LAUDERDALE
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33301-2046
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 954-994-1312
-----------------------------------------------------
Fax | 954-466-3888
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | GINTARAS RAZAITIS
-----------------------------------------------------
Credential | PMHNP-BC, FNP-C
-----------------------------------------------------
Telephone | 954-994-1312
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 2084B0040X
-----------------------------------------------------
Taxonomy Name | Behavioral Neurology & Neuropsychiatry Physician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 2084P0802X
-----------------------------------------------------
Taxonomy Name | Addiction Psychiatry Physician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #3
-----------------------------------------------------
Taxonomy Code | 2084P0800X
-----------------------------------------------------
Taxonomy Name | Psychiatry Physician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------