Provider Demographics
NPI:1174608699
Name:VANGUARD MEDICAL GROUP, LLC
Entity type:Organization
Organization Name:VANGUARD MEDICAL GROUP, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRACTICE ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:ROBYN
Authorized Official - Middle Name:
Authorized Official - Last Name:PAPPAS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:954-362-2691
Mailing Address - Street 1:603 N FLAMINGO RD
Mailing Address - Street 2:SUITE 150
Mailing Address - City:PEMBROKE PINES
Mailing Address - State:FL
Mailing Address - Zip Code:33028-1023
Mailing Address - Country:US
Mailing Address - Phone:954-436-6660
Mailing Address - Fax:954-436-6655
Practice Address - Street 1:603 N FLAMINGO RD
Practice Address - Street 2:SUITE 150
Practice Address - City:PEMBROKE PINES
Practice Address - State:FL
Practice Address - Zip Code:33028-1023
Practice Address - Country:US
Practice Address - Phone:954-436-6660
Practice Address - Fax:954-436-6655
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-25
Last Update Date:2012-10-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME80305174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLAC836Medicare PIN