1619321684 NPI number — MIVIP ANESTHESIA 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 1619321684 NPI number — MIVIP ANESTHESIA GROUP LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
MIVIP ANESTHESIA 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:
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:
1619321684
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
07/21/2022
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
398 CAMINO GARDENS BLVD
Provider Second Line Business Mailing Address:
SUITE 102
Provider Business Mailing Address City Name:
BOCA RATON
Provider Business Mailing Address State Name:
FL
Provider Business Mailing Address Postal Code:
33432-5827
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
561-392-3341
Provider Business Mailing Address Fax Number:
561-392-3793

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
11801 SW 90TH ST
Provider Second Line Business Practice Location Address:
SUITE 202
Provider Business Practice Location Address City Name:
MIAMI
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
33186-2182
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
305-595-6850
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
04/15/2016

Additional Information

Authorized Official

Authorized Official Last Name:
VERBUKH
Authorized Official First Name:
ISAAC
Authorized Official Middle Name:
Authorized Official Title or Position:
SOLE MBR
Authorized Official Telephone Number:
561-392-3341

Provider Taxonomy Codes

  • Taxonomy code: 261QH0100X , registered in the state of FL ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: L16000067973 . This is a "DOCUMENT NUMBER" identifier , issued by the state of ( FL ) . This identifiers is of the category "OTHER".




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