MEDICARE: DR. MICHAEL FISH PH.D.

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	103T00000X	Psychologist	PY3726	FL

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	056610	OTHER	FL	VALUE OPTIONS
2	73683	OTHER	FL	BLUE CROSS/BLUE SHIELD

General Provider Information

NPI Number	:	1548358294
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. MICHAEL FISH PH.D.

Provider Business Mailing Address
First Line	:	4581 WESTON RD STE 374
Second Line	:
City	:	WESTON
State	:	FL
Zip	:	33331-3141
Country	:	US
Telephone Number	:	954-370-7692
Fax Number	:	954-370-2383

Provider Business Practice Location Address
First Line	:	10200 W STATE ROAD 84 STE 105
Second Line	:
City	:	DAVIE
State	:	FL
Zip	:	33324-4218
Country	:	US
Telephone Number	:	954-370-7692
Fax Number	:	954-370-2383

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

Provider Enumeration Date	:	10/10/2006
Last Update Date	:	03/17/2018

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