Provider Demographics
NPI:1417233222
Name:PROFESSIONAL MEDICAL SERVICES & MANAGEMENT INC.
Entity Type:Organization
Organization Name:PROFESSIONAL MEDICAL SERVICES & MANAGEMENT INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT/ CEO
Authorized Official - Prefix:
Authorized Official - First Name:SANDY
Authorized Official - Middle Name:
Authorized Official - Last Name:LOPEZ
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:786-360-4528
Mailing Address - Street 1:315 W 9TH ST
Mailing Address - Street 2:SECOND FLOOR
Mailing Address - City:HIALEAH
Mailing Address - State:FL
Mailing Address - Zip Code:33010-3853
Mailing Address - Country:US
Mailing Address - Phone:786-360-4528
Mailing Address - Fax:786-360-4529
Practice Address - Street 1:315 W 9TH ST FL 2
Practice Address - Street 2:
Practice Address - City:HIALEAH
Practice Address - State:FL
Practice Address - Zip Code:33010-3853
Practice Address - Country:US
Practice Address - Phone:786-360-4528
Practice Address - Fax:786-360-4529
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-10-25
Last Update Date:2022-01-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL208D00000X
261Q00000X, 261QM1300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261QM1300XAmbulatory Health Care FacilitiesClinic/CenterMulti-Specialty
No208D00000XAllopathic & Osteopathic PhysiciansGeneral PracticeGroup - Single Specialty
No261Q00000XAmbulatory Health Care FacilitiesClinic/CenterGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLME51845OtherMEDICAL LICENSE
FL000645500Medicaid
FL05710FLMedicare Oscar/Certification
FL000645500Medicaid