Provider Demographics
NPI:1245381052
Name:M F FERNANDEZ MD KELLY MEDICAL CENTER CO INC
Entity Type:Organization
Organization Name:M F FERNANDEZ MD KELLY MEDICAL CENTER CO INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:MANUEL
Authorized Official - Middle Name:F
Authorized Official - Last Name:FERNANDEZ
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:305-245-7787
Mailing Address - Street 1:29613 SW 162ND AVE
Mailing Address - Street 2:
Mailing Address - City:HOMESTEAD
Mailing Address - State:FL
Mailing Address - Zip Code:33033-3328
Mailing Address - Country:US
Mailing Address - Phone:305-245-7787
Mailing Address - Fax:305-245-7740
Practice Address - Street 1:29613 SW 162ND AVE
Practice Address - Street 2:
Practice Address - City:HOMESTEAD
Practice Address - State:FL
Practice Address - Zip Code:33033-3328
Practice Address - Country:US
Practice Address - Phone:305-245-7787
Practice Address - Fax:305-245-7740
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-16
Last Update Date:2008-07-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME66369208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral PracticeGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL373393901Medicaid
FL373393901Medicaid