Provider Demographics
NPI:1619321684
Name:MIVIP ANESTHESIA GROUP LLC
Entity Type:Organization
Organization Name:MIVIP ANESTHESIA GROUP LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:SOLE MBR
Authorized Official - Prefix:DR
Authorized Official - First Name:ISAAC
Authorized Official - Middle Name:
Authorized Official - Last Name:VERBUKH
Authorized Official - Suffix:
Authorized Official - Credentials:
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:561-392-3793
Practice Address - Street 1:11801 SW 90TH ST
Practice Address - Street 2:SUITE 202
Practice Address - City:MIAMI
Practice Address - State:FL
Practice Address - Zip Code:33186-2182
Practice Address - Country:US
Practice Address - Phone:305-595-6850
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-04-15
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL261QH0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QH0100XAmbulatory Health Care FacilitiesClinic/CenterHealth Service
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLL16000067973OtherDOCUMENT NUMBER