Provider Demographics
NPI:1225075575
Name:MCJ MEDICAL CENTER CORP
Entity Type:Organization
Organization Name:MCJ MEDICAL CENTER CORP
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:MR
Authorized Official - First Name:IGMAR
Authorized Official - Middle Name:
Authorized Official - Last Name:CHANG
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:305-468-1714
Mailing Address - Street 1:3900 NW 79TH AVE
Mailing Address - Street 2:SUITE 728
Mailing Address - City:DORAL
Mailing Address - State:FL
Mailing Address - Zip Code:33166-6556
Mailing Address - Country:US
Mailing Address - Phone:305-468-1714
Mailing Address - Fax:305-468-1757
Practice Address - Street 1:3900 NW 79TH AVE
Practice Address - Street 2:SUITE 728
Practice Address - City:DORAL
Practice Address - State:FL
Practice Address - Zip Code:33166-6556
Practice Address - Country:US
Practice Address - Phone:305-468-1714
Practice Address - Fax:305-468-1757
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-02
Last Update Date:2009-11-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLHCC5974261Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/Center
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLK8366Medicare PIN