Provider Demographics
NPI:1194391896
Name:CONVIVA MEDICAL CENTER MANAGEMENT LLC
Entity Type:Organization
Organization Name:CONVIVA MEDICAL CENTER MANAGEMENT LLC
Other - Org Name:CONVIVA SOUTH TAMPA
Other - Org Type:Other Name
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:OFELIA
Authorized Official - Middle Name:
Authorized Official - Last Name:BURGOS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:305-500-2000
Mailing Address - Street 1:6101 BLUE LAGOON DR STE 200
Mailing Address - Street 2:
Mailing Address - City:MIAMI
Mailing Address - State:FL
Mailing Address - Zip Code:33126-3168
Mailing Address - Country:US
Mailing Address - Phone:305-500-2000
Mailing Address - Fax:
Practice Address - Street 1:200 S MACDILL AVE
Practice Address - Street 2:
Practice Address - City:TAMPA
Practice Address - State:FL
Practice Address - Zip Code:33609-3532
Practice Address - Country:US
Practice Address - Phone:813-837-2814
Practice Address - Fax:813-839-4336
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:CONVIVA MEDICAL CENTER MANAGEMENT LLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2021-06-02
Last Update Date:2022-09-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty
No207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
No208D00000XAllopathic & Osteopathic PhysiciansGeneral PracticeGroup - Multi-Specialty