Provider Demographics
NPI:1477303055
Name:ID&WM LLC
Entity type:Organization
Organization Name:ID&WM LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:ALEXANDER
Authorized Official - Middle Name:
Authorized Official - Last Name:BIRUKOFF
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:754-777-1333
Mailing Address - Street 1:1328 SE 17TH ST
Mailing Address - Street 2:
Mailing Address - City:FORT LAUDERDALE
Mailing Address - State:FL
Mailing Address - Zip Code:33316-1708
Mailing Address - Country:US
Mailing Address - Phone:754-777-1333
Mailing Address - Fax:
Practice Address - Street 1:1328 SE 17TH ST
Practice Address - Street 2:
Practice Address - City:FORT LAUDERDALE
Practice Address - State:FL
Practice Address - Zip Code:33316-1708
Practice Address - Country:US
Practice Address - Phone:754-777-1333
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2024-03-25
Last Update Date:2025-07-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RE0101XAllopathic & Osteopathic PhysiciansInternal MedicineEndocrinology, Diabetes & MetabolismGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLST035Medicaid
FL1063775674Medicaid
FLST058Medicaid
FL1477303055Medicaid
FL1295597664Medicaid