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General NPI Number Information
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NPI Number | 1609898683
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Entity Type | Organization
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Legal Business Name | ST. GEORGE SPINAL CLINIC PA
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Dates
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Enumeration Date | 07/25/2006
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Last Update Date | 08/26/2011
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Provider Practice Location Address
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Address Line | 4469 N STATE ROAD 7
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City | LAUDERDALE LAKES
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State | FL
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Zip | 33319-5876
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Country | US
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Telephone | 954-486-1966
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Fax | 954-486-9115
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Provider Business Mailing Address
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Address Line | PO BOX 10693
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City | RIVIERA BEACH
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State | FL
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Zip | 33419-0693
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Country | US
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Telephone | 954-486-1966
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Fax | 954-486-9115
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Authorized Official
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Title or Position | PHYSICIAN
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Name | DR. WAGDY B. TADROS
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Credential | MD
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Telephone | 954-486-1966
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 207R00000X
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Taxonomy Name | Internal Medicine Physician
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License Number | ME65248
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License Number State | FL
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