Provider Demographics
NPI:1619303112
Name:MGM IPA DADE 001 LLC
Entity Type:Organization
Organization Name:MGM IPA DADE 001 LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO/PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:MARIO
Authorized Official - Middle Name:ARMANDO
Authorized Official - Last Name:ESPINO
Authorized Official - Suffix:JR
Authorized Official - Credentials:
Authorized Official - Phone:786-395-1165
Mailing Address - Street 1:8318 SW 193RD ST
Mailing Address - Street 2:
Mailing Address - City:CUTLER BAY
Mailing Address - State:FL
Mailing Address - Zip Code:33157-8085
Mailing Address - Country:US
Mailing Address - Phone:305-964-5119
Mailing Address - Fax:
Practice Address - Street 1:8318 SW 193RD ST
Practice Address - Street 2:
Practice Address - City:CUTLER BAY
Practice Address - State:FL
Practice Address - Zip Code:33157-8085
Practice Address - Country:US
Practice Address - Phone:305-964-5119
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-09-17
Last Update Date:2013-09-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty
No208D00000XAllopathic & Osteopathic PhysiciansGeneral PracticeGroup - Multi-Specialty
No302F00000XManaged Care OrganizationsExclusive Provider OrganizationGroup - Multi-Specialty