Provider Demographics
NPI:1063688406
Name:MCCRAE, BERNICE
Entity Type:Individual
Prefix:
First Name:BERNICE
Middle Name:
Last Name:MCCRAE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1311 NW 98TH TER
Mailing Address - Street 2:
Mailing Address - City:MIAMI
Mailing Address - State:FL
Mailing Address - Zip Code:33147-2663
Mailing Address - Country:US
Mailing Address - Phone:305-696-5106
Mailing Address - Fax:
Practice Address - Street 1:1311 NW 98TH TER
Practice Address - Street 2:
Practice Address - City:MIAMI
Practice Address - State:FL
Practice Address - Zip Code:33147-2663
Practice Address - Country:US
Practice Address - Phone:305-696-5106
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-05-06
Last Update Date:2008-05-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLCHS 0307-701-88171W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171W00000XOther Service ProvidersContractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL230498800OtherMEDICAID PROBVIDER NUMBER