1457314064 NPI number — VITAL MEDICAL CENTER 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 1457314064 NPI number — VITAL MEDICAL CENTER INC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
VITAL MEDICAL CENTER 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:
1457314064
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
03/29/2017
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
8300 W FLAGLER ST
Provider Second Line Business Mailing Address:
SUITE #175
Provider Business Mailing Address City Name:
MIAMI
Provider Business Mailing Address State Name:
FL
Provider Business Mailing Address Postal Code:
33144-6000
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
305-220-0300
Provider Business Mailing Address Fax Number:
305-220-1472

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
8300 WEST FLASLER STREET
Provider Second Line Business Practice Location Address:
SUITE #175
Provider Business Practice Location Address City Name:
MIAMI
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
33144-2098
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
305-220-0300
Provider Business Practice Location Address Fax Number:
305-220-1472
Provider Enumeration Date:
04/07/2006

Additional Information

Authorized Official

Authorized Official Last Name:
LORA
Authorized Official First Name:
FERNANDO
Authorized Official Middle Name:
JOSE
Authorized Official Title or Position:
MD
Authorized Official Telephone Number:
305-220-0300

Provider Taxonomy Codes

  • Taxonomy code: 174400000X , with the licence number:  ME0045837 , 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: 0125792 . This is a "AETNA" identifier . This identifiers is of the category "OTHER".
  • Identifier: 042148100 , issued by the state of ( FL ) . This identifiers is of the category "MEDICAID".
  • Identifier: 96904 . This is a "BLUE CROSS BLUE SHIELD" identifier , issued by the state of ( FL ) . This identifiers is of the category "OTHER".
  • Identifier: 011862200 . 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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