Provider Demographics
NPI:1407185671
Name:MID FLORIDA ADULT MEDICINE, LLC
Entity Type:Organization
Organization Name:MID FLORIDA ADULT MEDICINE, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT/OWNER
Authorized Official - Prefix:
Authorized Official - First Name:MANUEL
Authorized Official - Middle Name:
Authorized Official - Last Name:IGLESIAS
Authorized Official - Suffix:
Authorized Official - Credentials:CEO
Authorized Official - Phone:786-641-5348
Mailing Address - Street 1:8750 NW 36TH ST
Mailing Address - Street 2:SUITE 300
Mailing Address - City:DORAL
Mailing Address - State:FL
Mailing Address - Zip Code:33178-2425
Mailing Address - Country:US
Mailing Address - Phone:786-641-5348
Mailing Address - Fax:305-615-1121
Practice Address - Street 1:7824 LAKE UNDERHILL RD
Practice Address - Street 2:SUITE B
Practice Address - City:ORLANDO
Practice Address - State:FL
Practice Address - Zip Code:32822-8201
Practice Address - Country:US
Practice Address - Phone:407-281-0470
Practice Address - Fax:407-273-1848
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-12-16
Last Update Date:2017-02-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL1952357303Medicare PIN
FLD95888Medicare UPIN