=====================================================
General NPI Number Information
=====================================================
NPI Number | 1851766232
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | ELITE OBGYN PHYSICIANS PA
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 12/10/2015
-----------------------------------------------------
Last Update Date | 12/11/2018
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1951 SW 172ND AVE STE 212
-----------------------------------------------------
City | MIRAMAR
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33029-5613
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 954-666-0341
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 601 N FLAMINGO RD STE 406
-----------------------------------------------------
City | PEMBROKE PINES
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33028-1012
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 754-201-3700
-----------------------------------------------------
Fax | 754-201-3711
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT
-----------------------------------------------------
Name | STEFAN NOVAC
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 754-201-3700
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207V00000X
-----------------------------------------------------
Taxonomy Name | Obstetrics & Gynecology Physician
-----------------------------------------------------
License Number | ME122662
-----------------------------------------------------
License Number State | FL
-----------------------------------------------------