Provider Demographics
NPI:1114156452
Name:MIAMI DADE PRIMARY CARE LLC
Entity Type:Organization
Organization Name:MIAMI DADE PRIMARY CARE LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MGR
Authorized Official - Prefix:DR
Authorized Official - First Name:RAMON
Authorized Official - Middle Name:
Authorized Official - Last Name:CARRILLO
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:305-445-7200
Mailing Address - Street 1:3181 CORAL WAY
Mailing Address - Street 2:4TH FLOOR
Mailing Address - City:CORAL GABLES
Mailing Address - State:FL
Mailing Address - Zip Code:33145-3216
Mailing Address - Country:US
Mailing Address - Phone:305-445-7200
Mailing Address - Fax:305-445-7999
Practice Address - Street 1:2974 SW 8TH ST
Practice Address - Street 2:
Practice Address - City:MIAMI
Practice Address - State:FL
Practice Address - Zip Code:33135-2827
Practice Address - Country:US
Practice Address - Phone:305-631-3000
Practice Address - Fax:305-631-3009
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-07-08
Last Update Date:2010-06-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME0014314207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL049755000Medicaid
FL1548224116OtherNPI
FLD65614Medicare UPIN