Provider Demographics
NPI:1326047366
Name:GEMINI MEDICAL GROUP CORP
Entity Type:Organization
Organization Name:GEMINI MEDICAL GROUP CORP
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:VLADIMIR
Authorized Official - Middle Name:
Authorized Official - Last Name:DE LA CRUZ
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:305-752-8880
Mailing Address - Street 1:3900 NW 79TH AVE
Mailing Address - Street 2:SUITE 704
Mailing Address - City:DORAL
Mailing Address - State:FL
Mailing Address - Zip Code:33166-6556
Mailing Address - Country:US
Mailing Address - Phone:305-752-8880
Mailing Address - Fax:305-752-2366
Practice Address - Street 1:3900 NW 79TH AVE
Practice Address - Street 2:SUITE 704
Practice Address - City:DORAL
Practice Address - State:FL
Practice Address - Zip Code:33166-6556
Practice Address - Country:US
Practice Address - Phone:305-752-8880
Practice Address - Fax:305-752-2366
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-07-20
Last Update Date:2007-12-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2000XAmbulatory Health Care FacilitiesClinic/CenterPhysical Therapy
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL684868Medicare Oscar/Certification