MEDICARE: PHOENIX EMERGENCY MEDICINE OF BROWARD LLC

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	207P00000X	Emergency Medicine Physician	ME39895	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	:	1144279233
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	PHOENIX EMERGENCY MEDICINE OF BROWARD LLC

Provider Business Mailing Address
First Line	:	3114 CROASDAILE DR STE 200
Second Line	:	PHOENIX EMERGENCY MEDICINE OF BROWARD
City	:	DURHAM
State	:	NC
Zip	:	27705-2508
Country	:	US
Telephone Number	:	954-838-2371
Fax Number	:	919-425-0478

Provider Business Practice Location Address
First Line	:	200 NW 7TH AVE
Second Line	:	PHOENIX PHYSICIANS
City	:	FT LAUDERDALE
State	:	FL
Zip	:	33311-9026
Country	:	US
Telephone Number	:	954-759-6789
Fax Number	:	919-425-0478

Authorized Official
Title or Position	:	OFFICER
Name	:	KATHLEEN KONDAS
Credential	:
Telephone Number	:	954-838-2371

Provider Enumeration Date	:	05/08/2006
Last Update Date	:	09/11/2019

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