Provider Demographics
NPI:1447783220
Name:MATMED LLC
Entity Type:Organization
Organization Name:MATMED LLC
Other - Org Name:MIAMI WELLNESS
Other - Org Type:Doing Business As
Authorized Official - Title/Position:MD MBA
Authorized Official - Prefix:
Authorized Official - First Name:MIGUEL
Authorized Official - Middle Name:A
Authorized Official - Last Name:TELLERIA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:786-808-8555
Mailing Address - Street 1:9066 SW 73RD CT PH 2404
Mailing Address - Street 2:
Mailing Address - City:MIAMI
Mailing Address - State:FL
Mailing Address - Zip Code:33156-2972
Mailing Address - Country:US
Mailing Address - Phone:786-808-8555
Mailing Address - Fax:786-360-1100
Practice Address - Street 1:8501 SW 124TH AVE STE 110
Practice Address - Street 2:
Practice Address - City:MIAMI
Practice Address - State:FL
Practice Address - Zip Code:33183-4631
Practice Address - Country:US
Practice Address - Phone:786-808-8555
Practice Address - Fax:786-360-1100
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-04-07
Last Update Date:2023-09-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207LP2900XAllopathic & Osteopathic PhysiciansAnesthesiologyPain MedicineGroup - Multi-Specialty
No208VP0014XAllopathic & Osteopathic PhysiciansPain MedicineInterventional Pain MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL103418700Medicaid