| Entity Name: | MICHAEL FISH PHD, PA |
| Jurisdiction: | FLORIDA |
| Filing Type: | Domestic Profit |
| Status: | Active |
| Date Filed: | 25 Apr 1988 (37 years ago) |
| Document Number: | K21782 |
| FEI/EIN Number | 650038904 |
| Mail Address: | 4581 WESTON RD., WESTON, FL, 33331, US |
| Address: | 10200 W STATE RD 84, DAVIE, FL, 33324, US |
| ZIP code: | 33324 |
| County: | Broward |
| Place of Formation: | FLORIDA |
| NPI | Enumeration Date | Last Update Date | Mailing Address | Practice Location Address | |||||||||||||||||||||||||||||||
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| 1376723478 | 2007-11-06 | 2017-10-09 | 1304 SW 160TH AVE, SUITE 339, SUNRISE, FL, 333261902, US | 10200 W STATE ROAD 84 STE 105, DAVIE, FL, 333244218, US | |||||||||||||||||||||||||||||||
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| Phone | +1 954-370-7692 |
| Fax | 9543702383 |
Authorized person
| Name | DR. MICHAEL FISH |
| Role | PRESIDENT/PSYCHOLOGIST |
| Phone | 9543707692 |
Taxonomy
| Taxonomy Code | 103T00000X - Psychologist |
| License Number | PY3726 |
| State | FL |
| Is Primary | Yes |
Other Provider Identifiers
| Issuer | BLUE CROSS/BLUE SHIELD |
| Number | 73683 |
| State | FL |
| Issuer | VALUE OPTIONS/TRICARE |
| Number | 056610 |
| State | FL |
| Name | Role | Address |
|---|---|---|
| FISH MICHAEL D | Agent | 10200 W STATE RD 84, DAVIE, FL, 33324 |
| Name | Role | Address |
|---|---|---|
| FISH MICHAEL DR. | President | 10200 W STATE RD 84, DAVIE, FL, 33324 |
| Event Type | Filed Date | Value | Description |
|---|---|---|---|
| REINSTATEMENT | 1994-10-18 | No data | No data |
| ADMIN DISSOLUTION FOR ANNUAL REPORT | 1994-08-26 | No data | No data |
| Document Number | Status | Case Number | Name of Court | Date of Entry | Expiration Date | Amount Due | Plaintiff |
|---|---|---|---|---|---|---|---|
| J19000213312 | TERMINATED | 1000000819297 | BROWARD | 2019-03-12 | 2029-03-20 | $ 7,945.47 | STATE OF FLORIDA, DEPARTMENT OF REVENUE, CORAL SPRINGS SERVICE CENTER, 3301 N UNIVERSITY DR STE 200, CORAL SPRINGS FL330654149 |
| J14000609346 | TERMINATED | 1000000615475 | BROWARD | 2014-05-05 | 2024-05-09 | $ 967.59 | STATE OF FLORIDA, DEPARTMENT OF REVENUE, CORAL SPRINGS SERVICE CENTER, 3301 N UNIVERSITY DR STE 200, CORAL SPRINGS FL330654149 |
| J13000952102 | TERMINATED | 1000000497114 | BROWARD | 2013-05-16 | 2023-05-22 | $ 1,060.82 | STATE OF FLORIDA, DEPARTMENT OF REVENUE, CORAL SPRINGS SERVICE CENTER, 3301 N UNIVERSITY DR STE 200, CORAL SPRINGS FL330654149 |
Date of last update: 01 Feb 2025
Sources: Florida Department of State
