Provider Demographics
NPI:1477996544
Name:MIVIP MEDICAL GROUP INC
Entity Type:Organization
Organization Name:MIVIP MEDICAL GROUP INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWBER
Authorized Official - Prefix:
Authorized Official - First Name:ISAAC
Authorized Official - Middle Name:
Authorized Official - Last Name:VERBUKH
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:561-392-3341
Mailing Address - Street 1:398 CAMINO GARDENS BLVD
Mailing Address - Street 2:SUITE 102
Mailing Address - City:BOCA RATON
Mailing Address - State:FL
Mailing Address - Zip Code:33432-5827
Mailing Address - Country:US
Mailing Address - Phone:561-392-3341
Mailing Address - Fax:
Practice Address - Street 1:351 NW 42ND AVE
Practice Address - Street 2:SUITE 408
Practice Address - City:MIAMI
Practice Address - State:FL
Practice Address - Zip Code:33126-5683
Practice Address - Country:US
Practice Address - Phone:561-392-3341
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-04-09
Last Update Date:2015-01-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/Center
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL004L9OtherBCBSFL