=====================================================
General NPI Number Information
=====================================================
NPI Number | 1518015023
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | BROWARD QUALITY MEDICAL LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/08/2007
-----------------------------------------------------
Last Update Date | 08/22/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2500 E HALLANDALE BEACH BLVD SUITE 211
-----------------------------------------------------
City | HALLANDALE BEACH
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33009-4834
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 954-456-5533
-----------------------------------------------------
Fax | 954-456-6072
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2500 E HALLANDALE BEACH BLVD SUITE 211
-----------------------------------------------------
City | HALLANDALE BEACH
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33009-4834
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 954-456-5533
-----------------------------------------------------
Fax | 954-456-6072
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT
-----------------------------------------------------
Name | DR. MARIO MARKELIS
-----------------------------------------------------
Credential | M.D.
-----------------------------------------------------
Telephone | 954-456-5533
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 174400000X
-----------------------------------------------------
Taxonomy Name | Specialist
-----------------------------------------------------
License Number | ME37374
-----------------------------------------------------
License Number State | FL
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 174400000X
-----------------------------------------------------
Taxonomy Name | Specialist
-----------------------------------------------------
License Number | ME30744
-----------------------------------------------------
License Number State | FL
-----------------------------------------------------