Provider Demographics
NPI:1083647713
Name:MAGELLAN CLINICAL SERVICES LLC
Entity Type:Organization
Organization Name:MAGELLAN CLINICAL SERVICES LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:JORGE
Authorized Official - Middle Name:
Authorized Official - Last Name:CARBONELL
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:786-709-6977
Mailing Address - Street 1:7737 W 15TH CT
Mailing Address - Street 2:
Mailing Address - City:HIALEAH
Mailing Address - State:FL
Mailing Address - Zip Code:33014-3310
Mailing Address - Country:US
Mailing Address - Phone:786-709-6977
Mailing Address - Fax:
Practice Address - Street 1:255 SW 8TH ST
Practice Address - Street 2:STE 204
Practice Address - City:MIAMI
Practice Address - State:FL
Practice Address - Zip Code:33130-3529
Practice Address - Country:US
Practice Address - Phone:305-642-7245
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-08
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLHCC6604207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLK8785Medicare ID - Type Unspecified