Provider Demographics
NPI:1003944562
Name:PMG PROFESSIONAL MEDICAL GROUP INC
Entity Type:Organization
Organization Name:PMG PROFESSIONAL MEDICAL GROUP INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:EDGAR
Authorized Official - Middle Name:E
Authorized Official - Last Name:TARRAU
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:305-541-6545
Mailing Address - Street 1:2140 WEST FLAGLER ST
Mailing Address - Street 2:SUITE 210
Mailing Address - City:MIAMI
Mailing Address - State:FL
Mailing Address - Zip Code:33135
Mailing Address - Country:US
Mailing Address - Phone:305-541-6545
Mailing Address - Fax:305-541-6544
Practice Address - Street 1:2140 WEST FLAGLER ST
Practice Address - Street 2:SUITE 210
Practice Address - City:MIAMI
Practice Address - State:FL
Practice Address - Zip Code:33135
Practice Address - Country:US
Practice Address - Phone:305-541-6545
Practice Address - Fax:305-541-6544
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-28
Last Update Date:2008-09-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLK8152Medicare ID - Type Unspecified