1700242617 NPI number — CARLOS MEDINA MD PA

Table of content: WILLIAM JOSEPH SIGNORILE MD (NPI 1750965562)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1700242617 NPI number — CARLOS MEDINA MD PA

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
CARLOS MEDINA MD PA
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:
1700242617
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
10/15/2024
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1101 WATERSIDE LN
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
HOLLYWOOD
Provider Business Mailing Address State Name:
FL
Provider Business Mailing Address Postal Code:
33019-5005
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
21110 BISCAYNE BLVD STE 201
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
AVENTURA
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
33180-1251
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
786-817-7808
Provider Business Practice Location Address Fax Number:
786-551-2299
Provider Enumeration Date:
01/07/2016

Additional Information

Authorized Official

Authorized Official Last Name:
MEDINA
Authorized Official First Name:
CARLOS
Authorized Official Middle Name:
Authorized Official Title or Position:
OWNER
Authorized Official Telephone Number:
786-817-7808

Provider Taxonomy Codes

  • Taxonomy code: 2086S0122X , with the licence number:  ME106831 , 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: ME106831 . This is a "MEDICAL LICENSE" identifier , issued by the state of ( FL ) . This identifiers is of the category "OTHER".
  • Identifier: 023725900 . 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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