Provider Demographics
NPI:1477957967
Name:EXELSIOR MEDICAL GROUP, INC.
Entity Type:Organization
Organization Name:EXELSIOR MEDICAL GROUP, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:ALEXANDER
Authorized Official - Middle Name:
Authorized Official - Last Name:TIRADO
Authorized Official - Suffix:
Authorized Official - Credentials:PA-C
Authorized Official - Phone:305-944-1122
Mailing Address - Street 1:951 NE 167TH ST
Mailing Address - Street 2:SUITE 102
Mailing Address - City:NORTH MIAMI BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:33162-3711
Mailing Address - Country:US
Mailing Address - Phone:305-944-1122
Mailing Address - Fax:305-944-1133
Practice Address - Street 1:951 NE 167TH ST
Practice Address - Street 2:SUITE 102
Practice Address - City:NORTH MIAMI BEACH
Practice Address - State:FL
Practice Address - Zip Code:33162-3711
Practice Address - Country:US
Practice Address - Phone:305-944-1122
Practice Address - Fax:305-944-1133
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-10-14
Last Update Date:2014-10-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPA9107461207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL010736200Medicaid
FLPA9107461OtherPA-C
FLHW621ZMedicare PIN