| Entity Name: | ADIB ANTOINE CHIDIAC M.D., P.A. |
| Jurisdiction: | FLORIDA |
| Filing Type: | Florida Profit Corporation |
| Status: | Active |
| Date Filed: | 14 May 1984 (41 years ago) |
| Last Event: | NAME CHANGE AMENDMENT |
| Event Date Filed: | 14 Dec 2012 (12 years ago) |
| Document Number: | M00536 |
| FEI/EIN Number | 59-2411629 |
| Address: | 601 East Sample Road, Suite 103, Deerfield Beach, FL 33064 |
| Mail Address: | 3700 NE 31 Avenue, LIGHTHOUSE POINT, FL 33064 |
| ZIP code: | 33064 |
| County: | Broward |
| Place of Formation: | FLORIDA |
| NPI | Enumeration Date | Last Update Date | Mailing Address | Practice Location Address | |||||||||||||||||||||||||||
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| 1215057922 | 2007-03-29 | 2024-05-15 | 3700 NE 31ST AVE, LIGHTHOUSE POINT, FL, 330648431, US | 601 E SAMPLE RD STE 103, DEERFIELD BEACH, FL, 330644443, US | |||||||||||||||||||||||||||
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| Phone | +1 954-366-6039 |
| Fax | 9543666851 |
Authorized person
| Name | DR. ADIB ANTOINE CHIDIAC |
| Role | DOCTOR |
| Phone | 9543666039 |
Taxonomy
| Taxonomy Code | 207V00000X - Obstetrics & Gynecology Physician |
| Is Primary | Yes |
Other Provider Identifiers
| Issuer | MEDICAID |
| Number | 370810100 |
| State | FL |
| Issuer | PTAN |
| Number | 39167 |
| State | FL |
| Name | Role | Address |
|---|---|---|
| CHIDIAC, ADIB ANTOINE | Agent | 3700 NE 31 Avenue, LIGHTHOUSE POINT, FL 33064 |
| Name | Role | Address |
|---|---|---|
| CHIDIAC, ADIB ANTOINE | President | 3700 NE 31 Avenue, LIGHTHOUSE POINT, FL 33064 |
| Name | Role | Address |
|---|---|---|
| CHIDIAC, ADIB ANTOINE | Secretary | 3700 NE 31 Avenue, LIGHTHOUSE POINT, FL 33064 |
| Name | Role | Address |
|---|---|---|
| CHIDIAC, ADIB ANTOINE | Director | 3700 NE 31 Avenue, LIGHTHOUSE POINT, FL 33064 |
| Registration Number | Fictitious Name | Status | Filed Date | Expiration Date | Cancellation Date | Mailing Address |
|---|---|---|---|---|---|---|
| G11000014783 | SAMPLE OB-GYN | EXPIRED | 2011-02-07 | 2016-12-31 | No data | 601 EAST SAMPLE ROAD, SUITE 103, DEERFIELD BEACH, FL, 33064 |
| Event Type | Filed Date | Value | Description |
|---|---|---|---|
| CHANGE OF PRINCIPAL ADDRESS | 2021-04-12 | 601 East Sample Road, Suite 103, Deerfield Beach, FL 33064 | No data |
| CHANGE OF MAILING ADDRESS | 2020-06-10 | 601 East Sample Road, Suite 103, Deerfield Beach, FL 33064 | No data |
| REGISTERED AGENT ADDRESS CHANGED | 2020-06-10 | 3700 NE 31 Avenue, LIGHTHOUSE POINT, FL 33064 | No data |
| NAME CHANGE AMENDMENT | 2012-12-14 | ADIB ANTOINE CHIDIAC M.D., P.A. | No data |
| AMENDMENT AND NAME CHANGE | 2012-04-09 | SAMPLE OBSTETRICS & GYNECOLOGY, P.A. | No data |
| Name | Date |
|---|---|
| ANNUAL REPORT | 2024-03-05 |
| ANNUAL REPORT | 2023-01-23 |
| ANNUAL REPORT | 2022-02-24 |
| Off/Dir Resignation | 2021-04-26 |
| ANNUAL REPORT | 2021-04-12 |
| ANNUAL REPORT | 2020-06-10 |
| ANNUAL REPORT | 2019-05-10 |
| ANNUAL REPORT | 2018-04-28 |
| ANNUAL REPORT | 2017-04-22 |
| ANNUAL REPORT | 2016-04-26 |
Date of last update: 04 Feb 2025
Sources: Florida Department of State
