Provider Demographics
NPI:1518228287
Name:COCONUT GROVE MEDICAL CORPORATION
Entity Type:Organization
Organization Name:COCONUT GROVE MEDICAL CORPORATION
Other - Org Name:MICHAEL E. JOHNSON, MD
Other - Org Type:Doing Business As
Authorized Official - Title/Position:MD/OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:EUGENE
Authorized Official - Last Name:JOHNSON
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:305-856-5170
Mailing Address - Street 1:2250 S DIXIE HWY
Mailing Address - Street 2:SUITE 1
Mailing Address - City:MIAMI
Mailing Address - State:FL
Mailing Address - Zip Code:33133-2360
Mailing Address - Country:US
Mailing Address - Phone:305-856-5170
Mailing Address - Fax:305-856-9063
Practice Address - Street 1:2250 S DIXIE HWY
Practice Address - Street 2:SUITE 1
Practice Address - City:MIAMI
Practice Address - State:FL
Practice Address - Zip Code:33133-2360
Practice Address - Country:US
Practice Address - Phone:305-856-5170
Practice Address - Fax:305-856-9063
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-05-30
Last Update Date:2012-05-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME56901261QP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care