MEDICARE: MANOR MEDICAL CENTER INC.

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	207R00000X	Internal Medicine Physician	ME49891	FL

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1114228368
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	MANOR MEDICAL CENTER INC.

Provider Business Mailing Address
First Line	:	1040 NW 10TH AVE
Second Line	:
City	:	FORT LAUDERDALE
State	:	FL
Zip	:	33311-6101
Country	:	US
Telephone Number	:	954-728-9200
Fax Number	:	954-728-8660

Provider Business Practice Location Address
First Line	:	1000 NW 10TH AVE
Second Line	:
City	:	FORT LAUDERDALE
State	:	FL
Zip	:	33311-6137
Country	:	US
Telephone Number	:	954-728-9200
Fax Number	:	954-728-8660

Authorized Official
Title or Position	:	MEDICAL DOCTOR
Name	:	YVES MICHEL ANTOINE JODESTY SR.
Credential	:	MD
Telephone Number	:	954-728-9200

Provider Enumeration Date	:	11/04/2010
Last Update Date	:	02/17/2022

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