Provider Demographics
NPI:1457314064
Name:VITAL MEDICAL CENTER INC
Entity Type:Organization
Organization Name:VITAL MEDICAL CENTER INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MD
Authorized Official - Prefix:
Authorized Official - First Name:FERNANDO
Authorized Official - Middle Name:JOSE
Authorized Official - Last Name:LORA
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:305-220-0300
Mailing Address - Street 1:8300 W FLAGLER ST
Mailing Address - Street 2:SUITE #175
Mailing Address - City:MIAMI
Mailing Address - State:FL
Mailing Address - Zip Code:33144-6000
Mailing Address - Country:US
Mailing Address - Phone:305-220-0300
Mailing Address - Fax:305-220-1472
Practice Address - Street 1:8300 WEST FLASLER STREET
Practice Address - Street 2:SUITE #175
Practice Address - City:MIAMI
Practice Address - State:FL
Practice Address - Zip Code:33144-2098
Practice Address - Country:US
Practice Address - Phone:305-220-0300
Practice Address - Fax:305-220-1472
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-04-07
Last Update Date:2017-03-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME0045837174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
0125792OtherAETNA
FL042148100Medicaid
FL96904OtherBLUE CROSS BLUE SHIELD
FL72690Medicare PIN
FL96904OtherBLUE CROSS BLUE SHIELD