Provider Demographics
NPI:1508172206
Name:CHOICE ONE MEDICAL GROUP LLC
Entity Type:Organization
Organization Name:CHOICE ONE MEDICAL GROUP LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:VP OPERATIONS & NETWORK MNGT
Authorized Official - Prefix:
Authorized Official - First Name:MARY
Authorized Official - Middle Name:C
Authorized Official - Last Name:MARTINEZ
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:954-703-6065
Mailing Address - Street 1:49 N FEDERAL HWY
Mailing Address - Street 2:STE 350
Mailing Address - City:POMPANO BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:33062-4304
Mailing Address - Country:US
Mailing Address - Phone:954-703-6065
Mailing Address - Fax:561-828-3372
Practice Address - Street 1:511 NE 3RD AVE
Practice Address - Street 2:
Practice Address - City:FORT LAUDERDALE
Practice Address - State:FL
Practice Address - Zip Code:33301-3235
Practice Address - Country:US
Practice Address - Phone:954-903-0468
Practice Address - Fax:561-828-3372
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-08-19
Last Update Date:2015-02-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
171W00000X, 261QH0100X
FL302F00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes171W00000XOther Service ProvidersContractorGroup - Multi-Specialty
No261QH0100XAmbulatory Health Care FacilitiesClinic/CenterHealth Service
No302F00000XManaged Care OrganizationsExclusive Provider OrganizationGroup - Multi-Specialty