Provider Demographics
NPI:1144279233
Name:PHOENIX EMERGENCY MEDICINE OF BROWARD LLC
Entity type:Organization
Organization Name:PHOENIX EMERGENCY MEDICINE OF BROWARD LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICER
Authorized Official - Prefix:
Authorized Official - First Name:KATHLEEN
Authorized Official - Middle Name:
Authorized Official - Last Name:KONDAS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:954-838-2371
Mailing Address - Street 1:3114 CROASDAILE DR STE 200
Mailing Address - Street 2:PHOENIX EMERGENCY MEDICINE OF BROWARD
Mailing Address - City:DURHAM
Mailing Address - State:NC
Mailing Address - Zip Code:27705-2508
Mailing Address - Country:US
Mailing Address - Phone:954-838-2371
Mailing Address - Fax:919-425-0478
Practice Address - Street 1:200 NW 7TH AVE
Practice Address - Street 2:PHOENIX PHYSICIANS
Practice Address - City:FT LAUDERDALE
Practice Address - State:FL
Practice Address - Zip Code:33311-9026
Practice Address - Country:US
Practice Address - Phone:954-759-6789
Practice Address - Fax:919-425-0478
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-08
Last Update Date:2019-09-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME39895207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL269118301Medicaid
FLK5350CMedicare PIN