MEDICARE: 5630 LLC

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	207R00000X	Internal Medicine Physician

General Provider Information

NPI Number	:	1942022413
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	5630 LLC

Provider Business Mailing Address
First Line	:	5630 OAKTREE AVE
Second Line	:
City	:	FORT LAUDERDALE
State	:	FL
Zip	:	33312-6375
Country	:	US
Telephone Number	:	847-571-4323
Fax Number	:

Provider Business Practice Location Address
First Line	:	5630 OAKTREE AVE
Second Line	:
City	:	FORT LAUDERDALE
State	:	FL
Zip	:	33312-6375
Country	:	US
Telephone Number	:	847-571-4323
Fax Number	:

Authorized Official
Title or Position	:	OWNER
Name	:	SAM JUDAH SUGAR
Credential	:	MD
Telephone Number	:	847-571-4323

Provider Enumeration Date	:	10/28/2024
Last Update Date	:	10/28/2024

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