Provider Demographics
NPI:1588377949
Name:ADVANCED MEDICAL PROVIDER INC
Entity type:Organization
Organization Name:ADVANCED MEDICAL PROVIDER INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MS
Authorized Official - First Name:JESSY
Authorized Official - Middle Name:
Authorized Official - Last Name:MADHUKAR
Authorized Official - Suffix:
Authorized Official - Credentials:NP
Authorized Official - Phone:954-600-8994
Mailing Address - Street 1:11510 SW 2ND ST
Mailing Address - Street 2:
Mailing Address - City:PLANTATION
Mailing Address - State:FL
Mailing Address - Zip Code:33325-2922
Mailing Address - Country:US
Mailing Address - Phone:954-600-8994
Mailing Address - Fax:
Practice Address - Street 1:1560 SAWGRASS CORPORATE PKWY FL 4
Practice Address - Street 2:
Practice Address - City:SUNRISE
Practice Address - State:FL
Practice Address - Zip Code:33323-2855
Practice Address - Country:US
Practice Address - Phone:954-600-8994
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-01-02
Last Update Date:2023-01-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes171000000XOther Service ProvidersMilitary Health Care ProviderGroup - Multi-Specialty
No261Q00000XAmbulatory Health Care FacilitiesClinic/CenterGroup - Multi-Specialty
No302F00000XManaged Care OrganizationsExclusive Provider Organization
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL1104080092Medicaid
HI1144234857Medicaid
123OtherN/A
FL1225233521Medicaid
FL1285743799Medicaid
FL1093700346Medicaid
FL1811979123Medicaid
FL1447629027Medicaid
FL1073520565Medicaid