Provider Demographics
NPI:1356017743
Name:PUBLIC HEALTH TRUST OF DADE COUNTY FLORIDA
Entity Type:Organization
Organization Name:PUBLIC HEALTH TRUST OF DADE COUNTY FLORIDA
Other - Org Name:JMG SPECIALTY PHYSICIANS
Other - Org Type:Doing Business As
Authorized Official - Title/Position:EXECUTIVE VP, CFO
Authorized Official - Prefix:
Authorized Official - First Name:MARK
Authorized Official - Middle Name:T
Authorized Official - Last Name:KNIGHT
Authorized Official - Suffix:
Authorized Official - Credentials:CFO
Authorized Official - Phone:305-585-8490
Mailing Address - Street 1:PO BOX 12493
Mailing Address - Street 2:
Mailing Address - City:MIAMI
Mailing Address - State:FL
Mailing Address - Zip Code:33101-2493
Mailing Address - Country:US
Mailing Address - Phone:305-585-5315
Mailing Address - Fax:
Practice Address - Street 1:1801 NW 9TH AVE FL 2
Practice Address - Street 2:
Practice Address - City:MIAMI
Practice Address - State:FL
Practice Address - Zip Code:33136-1101
Practice Address - Country:US
Practice Address - Phone:786-466-8490
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-08-17
Last Update Date:2022-02-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Multi-Specialty
No208D00000XAllopathic & Osteopathic PhysiciansGeneral PracticeGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL000957213Medicaid