Provider Demographics
NPI:1346356847
Name:BIRD RD MEDICAL CENTER INC
Entity Type:Organization
Organization Name:BIRD RD MEDICAL CENTER INC
Other - Org Name:BIRD ROAD PODIATRY
Other - Org Type:Other Name
Authorized Official - Title/Position:SECRETARY/TREASURER
Authorized Official - Prefix:
Authorized Official - First Name:DORA
Authorized Official - Middle Name:Q
Authorized Official - Last Name:REYES
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:305-551-3412
Mailing Address - Street 1:8485 SW 40TH STREET
Mailing Address - Street 2:102
Mailing Address - City:MIAMI
Mailing Address - State:FL
Mailing Address - Zip Code:33155-3262
Mailing Address - Country:US
Mailing Address - Phone:305-551-3412
Mailing Address - Fax:305-551-1945
Practice Address - Street 1:8485 SW 40TH STREET
Practice Address - Street 2:102
Practice Address - City:MIAMI
Practice Address - State:FL
Practice Address - Zip Code:33155-3262
Practice Address - Country:US
Practice Address - Phone:305-551-3412
Practice Address - Fax:305-551-1945
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-21
Last Update Date:2014-07-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL029791700Medicaid
FL77923Medicare PIN
FL063076400Medicaid