MEDICARE: OAKRIDGE MEDICAL GROUP

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	247100000X	Radiologic Technologist	JR3583900	FL

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	7726045	OTHER	FL	AETNA PROVIDER ID
2	SG067359	OTHER	FL	VISTA HLTHCR ID
3	498	OTHER	FL	TOTAL HLTH CHOICE ID
4	V2224	OTHER	FL	BC BS PROVIDER ID
5	221601	OTHER	FL	FDA#
6	280077	OTHER	FL	AVMED PROVIDER ID
7	00002536540 02	OTHER	FL	UNITED HLTHCR ID
8	214355	OTHER	FL	AMERIGROUP PROVIDER ID

General Provider Information

NPI Number	:	1912051228
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	OAKRIDGE MEDICAL GROUP

Provider Business Mailing Address
First Line	:	1000 NE 56TH ST
Second Line	:	ATTN BUSINESS OFFICE
City	:	FORT LAUDERDALE
State	:	FL
Zip	:	33334-4149
Country	:	US
Telephone Number	:	954-958-0606
Fax Number	:	954-776-0821

Provider Business Practice Location Address
First Line	:	1000 NE 56TH ST
Second Line	:	ATTN BUSINESS OFFICE
City	:	FORT LAUDERDALE
State	:	FL
Zip	:	33334-4149
Country	:	US
Telephone Number	:	954-958-0606
Fax Number	:	954-776-0821

Authorized Official
Title or Position	:	BUSINESS OFFICE MANAGER
Name	:	MR. FRITZ PHANORD
Credential	:
Telephone Number	:	954-958-0606

Provider Enumeration Date	:	01/23/2007
Last Update Date	:	08/22/2020

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Directions to “OAKRIDGE MEDICAL GROUP ” Practice Location

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