=====================================================
General NPI Number Information
=====================================================
NPI Number | 1720806219
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | SUNSHINE STATE HEALTH PLAN, INC.
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/02/2024
-----------------------------------------------------
Last Update Date | 10/02/2024
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1299 NW 40TH AVE
-----------------------------------------------------
City | LAUDERHILL
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33313-5857
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 412-952-5179
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1299 NW 40TH AVE
-----------------------------------------------------
City | LAUDERHILL
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33313-5857
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | DIRECTOR, ENCOUNTERS
-----------------------------------------------------
Name | DONALD CANOFARI
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 954-377-8521
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 302R00000X
-----------------------------------------------------
Taxonomy Name | Health Maintenance Organization
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------