Provider Demographics
NPI:1629529359
Name:RED DIAMOND MEDICAL GROUP LLC
Entity Type:Organization
Organization Name:RED DIAMOND MEDICAL GROUP LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:ALBERTO
Authorized Official - Middle Name:
Authorized Official - Last Name:BURGOS-TIBURCIO
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:305-261-0057
Mailing Address - Street 1:85 GRAND CANAL DR SUITE 107
Mailing Address - Street 2:
Mailing Address - City:MIAMI
Mailing Address - State:FL
Mailing Address - Zip Code:33144
Mailing Address - Country:US
Mailing Address - Phone:305-261-0057
Mailing Address - Fax:305-261-0058
Practice Address - Street 1:85 GRAND CANAL DR STE 107
Practice Address - Street 2:
Practice Address - City:MIAMI
Practice Address - State:FL
Practice Address - Zip Code:33144-2566
Practice Address - Country:US
Practice Address - Phone:305-261-0057
Practice Address - Fax:305-261-0058
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-10-18
Last Update Date:2016-10-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME104754261QH0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QH0100XAmbulatory Health Care FacilitiesClinic/CenterHealth Service
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL001381800Medicaid
FL001381800Medicaid