NPIMap

Organization Active NPI

South Broward Hospital District

Doing business as Memorial Primary Care Miramar MOB

  • Family Medicine Physician
  • Miramar, FL
National Provider Identifier
1194499863
Registry record updated Aug 5, 2021
On this page

Key facts

NPPES NPI Registry
Primary specialty
Family Medicine PhysicianTaxonomy code 207Q00000X
Legal business name
SOUTH BROWARD HOSPITAL DISTRICT
Doing business as
Memorial Primary Care Miramar MOB
Practice address
1951 SW 172ND Ave Ste 210
Miramar, FL 33029-5613
Phone
(954) 265-2789
NPI assigned
Aug 5, 2021
Last updated
Aug 5, 2021By the provider in NPPES
Organization subpart
Yes
Parent organization
SOUTH BROWARD HOSPITAL DISTRICTAs reported in NPPES

NPPES NPI Registry

Updated by the provider on Aug 5, 2021

Registry information is reported by the provider to CMS and is not verified. About this source

Authorized official

Name
Esther Surujon
Title
Cfo MPG, MPC and Ucc
Phone
(954) 265-6677

Specialties & licenses 1

Specialty (taxonomy)CodeLicenseStatePrimary
Family Medicine PhysicianGroup: 193200000X MULTI-SPECIALTY GROUP 207Q00000X Primary

Addresses

Primary practice location

1951 SW 172ND Ave Ste 210
Miramar, FL 33029-5613

Mailing address

2900 Corporate Way
Door D
Miramar, FL 33025-3925
Phone (954) 276-5685

Other names 1

  • Memorial Primary Care Miramar MOB Doing business as

Medicare participation

Medicare enrollment files
Medicare fee-for-service enrollment
Enrolled in FL

Enrollment records 1

Enrollment IDStateProvider typePAC IDDetails
O20211007000295 FL Part B Supplier - Hospital Department(S) 8123927373 Receives reassigned benefits from 6 practitioners
Practice locations: Miramar, FL

Laboratory certificates & supplier records

Derived by NPIMap

These CMS records do not include an NPI. They are shown because their name and street address match this provider’s.

CLIA laboratory certificates

CLIA numberLaboratoryCertificateExpires
10D2235197Memorial Primary Care Miramar Mob1951 SW 172ND Ave #210, Miramar, FL 33029Certificate of waiverSep 6, 2027

National Provider Directory

National Provider Directory
Tax ID family
Memorial Hospital Divis58 organizations share this tax ID, including this one
Part of
Memorial Hospital Divis

Organizations with this tax ID in the same state 24

This tax ID family is large, so up to 24 of its organizations in the same state are linked here.

View all 24

Ownership & related parties

All facility ownership & control disclosures 7

Facilities whose Medicare enrollment lists this provider’s PECOS associate ID as an owner or managing party.

FacilityTypeRoleSince
Memorial Hospital MiramarMiramar, FL, CCN 100285 Hospital Operational/Managerial Control
Other		 Mar 23, 2005
Mar 23, 2005
Memorial Regional HospitalHollywood, FL, CCN 100038 Hospital Operational/Managerial Control Jul 1, 1966
Memorial Rehabilitation InstituteHollywood, FL, CCN 10T038 Hospital Operational/Managerial Control Jun 1, 2017
Memorial Regional HospitalHollywood, FL, CCN 10S038 Hospital Operational/Managerial Control
Other		 Jan 1, 2016
Jan 1, 2020
Memorial Hospital WestPembroke Pines, FL, CCN 100281 Hospital Operational/Managerial Control
Other		 Feb 18, 2022
Oct 14, 2013
Memorial Hospital PembrokePembroke Pines, FL, CCN 100230 Hospital Operational/Managerial Control
Other		 Apr 1, 2020
Apr 1, 2020
Memorial Manor Nursing HomePembroke Pines, FL, CCN 105668 Skilled nursing facility 5% Or Greater Direct Ownership Interest (100%)
Operational/Managerial Control		 Jun 3, 1989
Jun 3, 1989

Practitioners & affiliated clinicians

Practitioners 6

Individual providers connected to this organization through Medicare benefit reassignment, Care Compare group membership or National Provider Directory roles, and the practitioner matching its NPPES authorized official.

NPI Registry JSON

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1628121600000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1628121600000",
    "number": "1194499863",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "2900 CORPORATE WAY",
            "address_2": "DOOR D",
            "city": "MIRAMAR",
            "state": "FL",
            "postal_code": "330253925",
            "telephone_number": "954-276-5685",
            "fax_number": "954-985-7074"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "1951 SW 172ND AVE STE 210",
            "city": "MIRAMAR",
            "state": "FL",
            "postal_code": "330295613",
            "telephone_number": "954-265-2789"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "SOUTH BROWARD HOSPITAL DISTRICT",
        "organizational_subpart": "YES",
        "parent_organization_legal_business_name": "SOUTH BROWARD HOSPITAL DISTRICT",
        "enumeration_date": "2021-08-05",
        "last_updated": "2021-08-05",
        "certification_date": "2021-08-05",
        "status": "A",
        "authorized_official_last_name": "SURUJON",
        "authorized_official_first_name": "ESTHER",
        "authorized_official_title_or_position": "CFO MPG, MPC AND UCC",
        "authorized_official_telephone_number": "954-265-6677"
    },
    "taxonomies": [
        {
            "code": "207Q00000X",
            "taxonomy_group": "193200000X MULTI-SPECIALTY GROUP",
            "desc": "Family Medicine",
            "state": null,
            "license": null,
            "primary": true
        }
    ],
    "identifiers": [],
    "endpoints": [],
    "other_names": [
        {
            "organization_name": "Memorial Primary Care Miramar MOB",
            "code": "3",
            "type": "Doing Business As"
        }
    ]
}

Other providers in Miramar, FL

Sources for this page

Verify at the official NPI Registry.