Provider Demographics
NPI:1386665438
Name:M A MEDICAL CENTER CORP
Entity Type:Organization
Organization Name:M A MEDICAL CENTER CORP
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:MARIO
Authorized Official - Middle Name:J
Authorized Official - Last Name:HERNANDEZ
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:954-316-8496
Mailing Address - Street 1:5450 S STATE ROAD 7
Mailing Address - Street 2:BAY 3
Mailing Address - City:DAVIE
Mailing Address - State:FL
Mailing Address - Zip Code:33314-6442
Mailing Address - Country:US
Mailing Address - Phone:954-316-8496
Mailing Address - Fax:954-316-8497
Practice Address - Street 1:5450 S STATE ROAD 7
Practice Address - Street 2:BAY 3
Practice Address - City:DAVIE
Practice Address - State:FL
Practice Address - Zip Code:33314-6442
Practice Address - Country:US
Practice Address - Phone:954-316-8496
Practice Address - Fax:954-316-8497
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-22
Last Update Date:2007-07-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLHCC6842261Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/Center
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLHCC6842OtherAHCA LICENSE