MEDICARE: SUNLIFE OB-GYN SERVICES OF FT LAUDERDALE 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	207V00000X	Obstetrics & Gynecology Physician	ME71138	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	:	1679681449
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	SUNLIFE OB-GYN SERVICES OF FT LAUDERDALE PA

Provider Business Mailing Address
First Line	:	PO BOX 945953
Second Line	:
City	:	ATLANTA
State	:	GA
Zip	:	30394-5953
Country	:	US
Telephone Number	:	954-522-2979
Fax Number	:	954-903-0633

Provider Business Practice Location Address
First Line	:	4101 NW 4TH ST
Second Line	:	SUITE 306
City	:	PLANTATION
State	:	FL
Zip	:	33317-2840
Country	:	US
Telephone Number	:	954-522-2979
Fax Number	:	954-903-0633

Authorized Official
Title or Position	:	PRESIDENT
Name	:	DR. WINSTON O BLISS
Credential	:	MD
Telephone Number	:	954-522-2979

Provider Enumeration Date	:	08/29/2006
Last Update Date	:	07/10/2012

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