MEDICARE: DR. SAM GERSHENBAUM D.O.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	208200000X	Plastic Surgery Physician	OS 000 5992	FL

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	80916	OTHER	FL	BLUE CROSS/BLUE SHIELD

General Provider Information

NPI Number	:	1013013127
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. SAM GERSHENBAUM D.O.

Provider Business Mailing Address
First Line	:	2954 AVENTURA BLVD # B
Second Line	:
City	:	AVENTURA
State	:	FL
Zip	:	33180-3103
Country	:	US
Telephone Number	:	305-933-1838
Fax Number	:	305-933-1850

Provider Business Practice Location Address
First Line	:	2954 AVENTURA BLVD # B
Second Line	:
City	:	AVENTURA
State	:	FL
Zip	:	33180-3103
Country	:	US
Telephone Number	:	305-933-1838
Fax Number	:	305-933-1850

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	09/15/2006
Last Update Date	:	07/08/2007

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