Provider Demographics
NPI:1376993980
Name:ADV AN CED FLORIDA MEDICAL GROUP, CORP.
Entity Type:Organization
Organization Name:ADV AN CED FLORIDA MEDICAL GROUP, CORP.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:ODALIS
Authorized Official - Middle Name:
Authorized Official - Last Name:MAZA MOREJON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:239-590-8570
Mailing Address - Street 1:3900 BROADWAY, SUITE D-9
Mailing Address - Street 2:
Mailing Address - City:FORT MYERS
Mailing Address - State:FL
Mailing Address - Zip Code:33901
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:3900 BROADWAY STE D-9
Practice Address - Street 2:
Practice Address - City:FORT MYERS
Practice Address - State:FL
Practice Address - Zip Code:33901-8193
Practice Address - Country:US
Practice Address - Phone:239-590-8570
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-06-14
Last Update Date:2016-09-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLHCC10633261Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/Center
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL1649626409OtherARNP