1629789417 NPI number — SOUTH FLORIDA MULTI-SPECIALTY MEDICAL GROUP LLC

Table of content: (NPI 1629789417)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1629789417 NPI number — SOUTH FLORIDA MULTI-SPECIALTY MEDICAL GROUP LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
SOUTH FLORIDA MULTI-SPECIALTY 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:
1629789417
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
12/13/2022
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
8950 SW 74TH CT STE 1408
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
MIAMI
Provider Business Mailing Address State Name:
FL
Provider Business Mailing Address Postal Code:
33156-3173
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
833-735-3668
Provider Business Mailing Address Fax Number:
866-897-7014

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1036 NW 1ST AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
HOMESTEAD
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
33030-4417
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
833-735-3668
Provider Business Practice Location Address Fax Number:
866-897-7014
Provider Enumeration Date:
12/12/2022

Additional Information

Authorized Official

Authorized Official Last Name:
HANNA
Authorized Official First Name:
PETER
Authorized Official Middle Name:
H
Authorized Official Title or Position:
CEO
Authorized Official Telephone Number:
833-735-3668

Provider Taxonomy Codes

  • Taxonomy code: 213ES0103X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 261QM1300X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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