Provider Demographics
NPI:1083910202
Name:GRISEL MAC WILLIAMS MD PA
Entity Type:Organization
Organization Name:GRISEL MAC WILLIAMS MD PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:MICHEL
Authorized Official - Middle Name:
Authorized Official - Last Name:DIAZ
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:305-691-7018
Mailing Address - Street 1:810 E 39TH PL
Mailing Address - Street 2:
Mailing Address - City:HIALEAH
Mailing Address - State:FL
Mailing Address - Zip Code:33013-2863
Mailing Address - Country:US
Mailing Address - Phone:305-691-7018
Mailing Address - Fax:305-691-5814
Practice Address - Street 1:810 E 39TH PL
Practice Address - Street 2:
Practice Address - City:HIALEAH
Practice Address - State:FL
Practice Address - Zip Code:33013-2863
Practice Address - Country:US
Practice Address - Phone:305-691-7018
Practice Address - Fax:305-691-5814
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-02-05
Last Update Date:2024-04-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
207R00000X
FLME0045706261Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/Center
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL047895400Medicaid
FLFC845AMedicare PIN
FL047895400Medicaid