Provider Demographics
NPI:1639215551
Name:MIDLAND MEDICAL MIAMI SHORES INC
Entity Type:Organization
Organization Name:MIDLAND MEDICAL MIAMI SHORES INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:NOAH
Authorized Official - Middle Name:J
Authorized Official - Last Name:LEE
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:305-751-9677
Mailing Address - Street 1:8642 NE 2ND AVE
Mailing Address - Street 2:
Mailing Address - City:MIAMI SHORES
Mailing Address - State:FL
Mailing Address - Zip Code:33138-3004
Mailing Address - Country:US
Mailing Address - Phone:305-751-9677
Mailing Address - Fax:305-751-9808
Practice Address - Street 1:8642 NE 2ND AVE
Practice Address - Street 2:
Practice Address - City:MIAMI SHORES
Practice Address - State:FL
Practice Address - Zip Code:33138-3004
Practice Address - Country:US
Practice Address - Phone:305-751-9677
Practice Address - Fax:305-751-9808
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-29
Last Update Date:2007-10-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLOS9305207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLAC355ZMedicare PIN