1235482480 NPI number — HEALTHSTONE 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 1235482480 NPI number — HEALTHSTONE MEDICAL GROUP, LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
HEALTHSTONE 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:
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:
1235482480
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
10/18/2015
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
2905 N COMMERCE PKWY
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
MIRAMAR
Provider Business Mailing Address State Name:
FL
Provider Business Mailing Address Postal Code:
33025-3957
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
954-967-6550
Provider Business Mailing Address Fax Number:
954-893-6818

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
21097 NE 27TH CT
Provider Second Line Business Practice Location Address:
SUITE 110
Provider Business Practice Location Address City Name:
AVENTURA
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
33180-1206
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
305-682-8809
Provider Business Practice Location Address Fax Number:
305-682-8623
Provider Enumeration Date:
10/24/2012

Additional Information

Authorized Official

Authorized Official Last Name:
POLNER
Authorized Official First Name:
BRIAN
Authorized Official Middle Name:
Authorized Official Title or Position:
MANAGER
Authorized Official Telephone Number:
954-967-6550

Provider Taxonomy Codes

  • Taxonomy code: 207R00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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