1578819769 NPI number — JORGE A HERNANDEZ P.A

Table of content: (NPI 1578819769)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1578819769 NPI number — JORGE A HERNANDEZ P.A

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
JORGE A HERNANDEZ P.A
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:
1578819769
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
12/06/2017
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
13315 SW 26TH ST
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:
33027-3875
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
787-598-1000
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
3410 W 84TH ST STE 100
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
HIALEAH
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
33018-4906
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
787-598-1000
Provider Business Practice Location Address Fax Number:
305-826-7774
Provider Enumeration Date:
07/25/2012

Additional Information

Authorized Official

Authorized Official Last Name:
HERNANDEZ
Authorized Official First Name:
JORGE
Authorized Official Middle Name:
A
Authorized Official Title or Position:
DIRECTOR/OWNER
Authorized Official Telephone Number:
787-598-1000

Provider Taxonomy Codes

  • Taxonomy code: 213ES0103X , with the licence number:  PO 3424 , 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: 00713700 , issued by the state of ( FL ) . This identifiers is of the category "MEDICAID".
  • Identifier: 101226500 . 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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