1801427463 NPI number — MART MEDICAL GROUP INC

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 1801427463 NPI number — MART MEDICAL GROUP INC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
MART MEDICAL GROUP INC
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:
1801427463
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
04/01/2024
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
6101 SW 76TH ST
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
SOUTH MIAMI
Provider Business Mailing Address State Name:
FL
Provider Business Mailing Address Postal Code:
33143-5021
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
305-342-4737
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
7311 NW 36TH ST UNIT 7311
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:
33166-6704
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
786-640-0602
Provider Business Practice Location Address Fax Number:
786-640-0603
Provider Enumeration Date:
01/31/2020

Additional Information

Authorized Official

Authorized Official Last Name:
MARTINEZ TORRES
Authorized Official First Name:
ROBERTO
Authorized Official Middle Name:
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
786-640-0602

Provider Taxonomy Codes

  • Taxonomy code: 208D00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 1047926 . This is a "DCF LICENSE" identifier , issued by the state of ( FL ) . This identifiers is of the category "OTHER".
  • Identifier: NG312 . This is a "AHCA" identifier , issued by the state of ( FL ) . This identifiers is of the category "OTHER".
  • Identifier: 1047924 . This is a "DCF LICENSE" identifier , issued by the state of ( FL ) . This identifiers is of the category "OTHER".
  • Identifier: 1047925 . This is a "INTENSIVE OUTPATIENT TREATMENT" identifier , issued by the state of ( FL ) . This identifiers is of the category "OTHER".
  • Identifier: 105437500 . 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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