Provider Demographics
NPI:1134642465
Name:EBENEZER MEDICAL CENTER LLC
Entity Type:Organization
Organization Name:EBENEZER MEDICAL CENTER LLC
Other - Org Name:EBENEZERMED
Other - Org Type:Former Legal Business Name
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:RENE
Authorized Official - Middle Name:ELADIO
Authorized Official - Last Name:DISOTUAR ABAD
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:305-330-5393
Mailing Address - Street 1:646 W PALM DR
Mailing Address - Street 2:
Mailing Address - City:HOMESTEAD
Mailing Address - State:FL
Mailing Address - Zip Code:33034-3208
Mailing Address - Country:US
Mailing Address - Phone:305-330-5393
Mailing Address - Fax:305-773-0220
Practice Address - Street 1:646 W PALM DR
Practice Address - Street 2:
Practice Address - City:HOMESTEAD
Practice Address - State:FL
Practice Address - Zip Code:33034-3208
Practice Address - Country:US
Practice Address - Phone:305-330-5393
Practice Address - Fax:305-773-0220
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-07-18
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL010733300Medicaid