Provider Demographics
NPI:1013211705
Name:SOUTH MIAMI SPORTS MEDICINE INC.
Entity Type:Organization
Organization Name:SOUTH MIAMI SPORTS MEDICINE INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT/OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:ROBERT
Authorized Official - Middle Name:A
Authorized Official - Last Name:MILLARES
Authorized Official - Suffix:
Authorized Official - Credentials:OTRL,CHT
Authorized Official - Phone:305-666-7116
Mailing Address - Street 1:7000 S.W. 62 AVENUE
Mailing Address - Street 2:SUITE 120
Mailing Address - City:MIAMI
Mailing Address - State:FL
Mailing Address - Zip Code:33143
Mailing Address - Country:US
Mailing Address - Phone:305-666-7168
Mailing Address - Fax:
Practice Address - Street 1:7000 SW 62ND AVE
Practice Address - Street 2:SUITE 120
Practice Address - City:SOUTH MIAMI
Practice Address - State:FL
Practice Address - Zip Code:33143-4716
Practice Address - Country:US
Practice Address - Phone:305-666-7168
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-01-10
Last Update Date:2011-01-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLOT2468302F00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes302F00000XManaged Care OrganizationsExclusive Provider Organization
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL=========OtherCIGNA,HUMANA,UNITED HEALTH CARE ,ASSURANCE