MEDICARE: DR. ETHAN BEN KASS DO MBA

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	2084P0800X	Psychiatry Physician	OS4676	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	:	1912991811
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. ETHAN BEN KASS DO MBA

Provider Business Mailing Address
First Line	:	4923 NW 57TH LN
Second Line	:
City	:	CORAL SPRINGS
State	:	FL
Zip	:	33067-2187
Country	:	US
Telephone Number	:	954-796-5010
Fax Number	:	954-796-9978

Provider Business Practice Location Address
First Line	:	8100 ROYAL PALM BLVD
Second Line	:	STE 103
City	:	CORAL SPRINGS
State	:	FL
Zip	:	33065-5733
Country	:	US
Telephone Number	:	954-796-5010
Fax Number	:	954-796-9978

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

Provider Enumeration Date	:	09/07/2005
Last Update Date	:	07/08/2007

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