Provider Demographics
NPI:1376655902
Name:IDEAL MEDICAL CENTER
Entity Type:Organization
Organization Name:IDEAL MEDICAL CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:WILFREDO
Authorized Official - Middle Name:
Authorized Official - Last Name:GONZALEZ
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:305-957-0017
Mailing Address - Street 1:995 N MIAMI BEACH BLVD
Mailing Address - Street 2:SUITE 100
Mailing Address - City:NORTH MIAMI BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:33162-3721
Mailing Address - Country:US
Mailing Address - Phone:305-957-0017
Mailing Address - Fax:305-957-0015
Practice Address - Street 1:995 N MIAMI BEACH BLVD
Practice Address - Street 2:SUITE 100
Practice Address - City:NORTH MIAMI BEACH
Practice Address - State:FL
Practice Address - Zip Code:33162-3721
Practice Address - Country:US
Practice Address - Phone:305-957-0017
Practice Address - Fax:305-957-0015
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-31
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL506207-2302R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes302R00000XManaged Care OrganizationsHealth Maintenance Organization
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL=========Medicare UPIN