=====================================================
General NPI Number Information
=====================================================
NPI Number | 1548037807
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | SUNSOUTH ST. JUDE HEALTH CARE, LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 12/07/2023
-----------------------------------------------------
Last Update Date | 12/12/2023
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 8374 PINES BLVD
-----------------------------------------------------
City | PEMBROKE PINES
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33024-6616
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 954-429-6986
-----------------------------------------------------
Fax | 954-429-6987
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 14690 SPRING HILL DR
-----------------------------------------------------
City | SPRING HILL
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 34609-8102
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | CEO
-----------------------------------------------------
Name | CARLOS ARIAS
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 352-277-5305
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207R00000X
-----------------------------------------------------
Taxonomy Name | Internal Medicine Physician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 208D00000X
-----------------------------------------------------
Taxonomy Name | General Practice Physician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------