MEDICARE: 360 MEDICAL PA

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	207RN0300X	Nephrology Physician	OS7637	FL

General Provider Information

NPI Number	:	1508096330
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	360 MEDICAL PA

Provider Business Mailing Address
First Line	:	2004 NE 49TH ST
Second Line	:
City	:	FORT LAUDERDALE
State	:	FL
Zip	:	33308-4524
Country	:	US
Telephone Number	:	954-790-2251
Fax Number	:	954-206-2200

Provider Business Practice Location Address
First Line	:	2004 NE 49TH ST
Second Line	:
City	:	FORT LAUDERDALE
State	:	FL
Zip	:	33308-4524
Country	:	US
Telephone Number	:	954-790-2251
Fax Number	:	954-206-2200

Authorized Official
Title or Position	:	PRESIDENT
Name	:	DR. LAN T PHAN
Credential	:	DO
Telephone Number	:	954-790-2251

Provider Enumeration Date	:	07/14/2009
Last Update Date	:	08/04/2009

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