Provider Demographics
NPI:1285203869
Name:CONVIVA MEDICAL CENTER MANAGEMENT LLC
Entity Type:Organization
Organization Name:CONVIVA MEDICAL CENTER MANAGEMENT LLC
Other - Org Name:CONVIVA MIDDLEBURG
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 1:1786 BLANDING BLVD STE 3
Practice Address - Street 2:
Practice Address - City:MIDDLEBURG
Practice Address - State:FL
Practice Address - Zip Code:32068-3804
Practice Address - Country:US
Practice Address - Phone:904-282-8000
Practice Address - Fax:904-282-8044
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:CONVIVA MEDICAL CENTER MANAGEMENT LLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2021-06-18
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