1306942602 NPI number — SYNOVATION MEDICAL GROUP, 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 1306942602 NPI number — SYNOVATION MEDICAL GROUP, LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
SYNOVATION MEDICAL GROUP, 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:
6
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:
1306942602
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
06/05/2024
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 12949
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:
33101-2949
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
954-457-0064
Provider Business Mailing Address Fax Number:
855-490-4044

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
7000 SW 62ND AVE STE 535
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
SOUTH MIAMI
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
33143-4724
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
786-268-4044
Provider Business Practice Location Address Fax Number:
866-206-8118
Provider Enumeration Date:
09/15/2006

Additional Information

Authorized Official

Authorized Official Last Name:
VARGA
Authorized Official First Name:
CLAYTON
Authorized Official Middle Name:
A
Authorized Official Title or Position:
MANAGER-MEMBER
Authorized Official Telephone Number:
305-428-7733

Provider Taxonomy Codes

  • Taxonomy code: 208VP0014X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 006820500 . 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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