=====================================================
General NPI Number Information
=====================================================
NPI Number | 1720274764
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | MARIO FAVILLI MD PA
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/24/2007
-----------------------------------------------------
Last Update Date | 03/06/2008
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 4855 W HILLSBORO BLVD SUITE B8
-----------------------------------------------------
City | COCONUT CREEK
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33073-4356
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 954-481-2278
-----------------------------------------------------
Fax | 954-481-1987
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 4855 W HILLSBORO BLVD SUITE B8
-----------------------------------------------------
City | COCONUT CREEK
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33073-4356
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 954-481-2278
-----------------------------------------------------
Fax | 954-481-1987
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | DR. MARIO NOEL FAVILLI
-----------------------------------------------------
Credential | MD
-----------------------------------------------------
Telephone | 954-481-2278
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207Q00000X
-----------------------------------------------------
Taxonomy Name | Family Medicine Physician
-----------------------------------------------------
License Number | ME0050696
-----------------------------------------------------
License Number State | FL
-----------------------------------------------------