Provider Demographics
NPI:1043525819
Name:STAR MEDICAL CLINIC, INC.
Entity Type:Organization
Organization Name:STAR MEDICAL CLINIC, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESDIENT (CEO)
Authorized Official - Prefix:MR
Authorized Official - First Name:LARRY
Authorized Official - Middle Name:
Authorized Official - Last Name:WHITFIELD
Authorized Official - Suffix:JR
Authorized Official - Credentials:
Authorized Official - Phone:443-804-5364
Mailing Address - Street 1:6112 NW 7TH AVE
Mailing Address - Street 2:
Mailing Address - City:MIAMI
Mailing Address - State:FL
Mailing Address - Zip Code:33127-1112
Mailing Address - Country:US
Mailing Address - Phone:786-360-2381
Mailing Address - Fax:305-456-4066
Practice Address - Street 1:6112 NW 7TH AVE
Practice Address - Street 2:
Practice Address - City:MIAMI
Practice Address - State:FL
Practice Address - Zip Code:33127-1112
Practice Address - Country:US
Practice Address - Phone:786-360-2381
Practice Address - Fax:305-456-4066
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-08-17
Last Update Date:2010-08-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL305R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes305R00000XManaged Care OrganizationsPreferred Provider Organization
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL269915000Medicaid