1942847496 NPI number — ATLANTIC MEDICAL CENTER DORAL 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 1942847496 NPI number — ATLANTIC MEDICAL CENTER DORAL INC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
ATLANTIC MEDICAL CENTER DORAL 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:
1942847496
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
12/03/2019
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
10900 NW 25TH ST STE 104
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
DORAL
Provider Business Mailing Address State Name:
FL
Provider Business Mailing Address Postal Code:
33172-1922
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
786-804-9521
Provider Business Mailing Address Fax Number:
305-716-9254

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
10900 NW 25TH ST STE 104
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
DORAL
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
33172-1922
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
786-804-9521
Provider Business Practice Location Address Fax Number:
305-716-9254
Provider Enumeration Date:
12/03/2019

Additional Information

Authorized Official

Authorized Official Last Name:
DIAZ
Authorized Official First Name:
ANA
Authorized Official Middle Name:
M
Authorized Official Title or Position:
PRESIDENT OWNER
Authorized Official Telephone Number:
786-804-9521

Provider Taxonomy Codes

  • Taxonomy code: 261Q00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 106264400 . 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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