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2151 E Commercial Blvd Suite 304 Fort Lauderdale FL 33308-4347 | |
| (954) 492-4525 | |
| Not Available |
| Full Name | |
|---|---|
| Speciality | Psychiatry & Neurology |
| Location | 2151 E Commercial Blvd, Fort Lauderdale, Florida |
| Authorized Official Name and Position | Dennis Michael Liston (CEO) |
| Authorized Official Contact | 9544924525 |
| Accepts Medicare Insurance | Yes. This clinic participates in medicare program and accept medicare insurance. |
| Mailing Address | Practice Location Address |
|---|---|
2151 E Commercial Blvd Suite 304 Fort Lauderdale FL 33308-4347 Ph: (954) 492-4525 | 2151 E Commercial Blvd Suite 304 Fort Lauderdale FL 33308-4347 Ph: (954) 492-4525 |
| NPI Number | 1619989308 |
|---|---|
| Provider Enumeration Date | 08/12/2006 |
| Last Update Date | 07/22/2013 |
| Medicare PECOS PAC ID | 8628076684 |
|---|---|
| Medicare Enrollment ID | O20061129000468 |
| Identifier | Type | State | Issuer |
|---|---|---|---|
| 1619989308 | NPI | - | NPPES |
| 277406200 | Medicaid | FL |
| Taxonomy | Type | License (State) | Status |
|---|---|---|---|
| 2084P0800X | Psychiatry & Neurology - Psychiatry | ME-0059446 (Florida) | Primary |
| Provider Name | Dennis M Liston |
|---|---|
| Provider Type | Practitioner - Psychiatry |
| Provider Identifiers | NPI Number: 1316995855 PECOS PAC ID: 5092714915 Enrollment ID: I20061204000226 |
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