1215475025 NPI number — MIAMI STROKE, LLC

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1215475025 NPI number — MIAMI STROKE, LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
MIAMI STROKE, LLC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1215475025
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
03/17/2018
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
13550 SW 120TH ST STE 502
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
MIAMI
Provider Business Mailing Address State Name:
FL
Provider Business Mailing Address Postal Code:
33186-7505
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
305-235-9550
Provider Business Mailing Address Fax Number:
305-235-0556

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
11750 SW 40TH ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
MIAMI
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
33175-3530
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
305-235-9550
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
02/01/2017

Additional Information

Authorized Official

Authorized Official Last Name:
COLEN
Authorized Official First Name:
JENNIFER
Authorized Official Middle Name:
Authorized Official Title or Position:
CREDENTIALING MANAGER
Authorized Official Telephone Number:
305-235-9550

Provider Taxonomy Codes

  • Taxonomy code: 2084V0102X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 23588R . This is a "P-TAN" identifier , issued by the state of ( FL ) . This identifiers is of the category "OTHER".
  • Identifier: 374074900 , issued by the state of ( FL ) . This identifiers is of the category "MEDICAID".
  • Identifier: 022390900 . This is a "Florida Medicaid Provider ID" identifier , issued by the state of ( FL ) . This identifiers is of the category "MEDICAID".




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