Provider Demographics
NPI:1831255363
Name:INFECTIOUS DISEASES ASSOCIATES OF FORT LAUDERDALE PA
Entity type:Organization
Organization Name:INFECTIOUS DISEASES ASSOCIATES OF FORT LAUDERDALE PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICIAN - PRESIDENT/OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:STEPHEN
Authorized Official - Middle Name:A
Authorized Official - Last Name:RENAE
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:954-772-7773
Mailing Address - Street 1:4750 N. FEDERAL HIGHWAY
Mailing Address - Street 2:SUITE 200
Mailing Address - City:FT. LAUDERDALE
Mailing Address - State:FL
Mailing Address - Zip Code:33308
Mailing Address - Country:US
Mailing Address - Phone:954-772-7773
Mailing Address - Fax:954-772-2221
Practice Address - Street 1:4750 N. FEDERAL HIGHWAY
Practice Address - Street 2:SUITE 200
Practice Address - City:FT. LAUDERDALE
Practice Address - State:FL
Practice Address - Zip Code:33308
Practice Address - Country:US
Practice Address - Phone:954-772-7773
Practice Address - Fax:954-772-2221
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-29
Last Update Date:2010-08-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RI0200XAllopathic & Osteopathic PhysiciansInternal MedicineInfectious DiseaseGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL255060100Medicaid
FL21260Medicare ID - Type Unspecified