Provider Demographics
NPI:1659940179
Name:SOUTH MIAMI MEDICAL GROUP LLC
Entity Type:Organization
Organization Name:SOUTH MIAMI MEDICAL GROUP LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICIAN
Authorized Official - Prefix:DR
Authorized Official - First Name:EDGAR
Authorized Official - Middle Name:
Authorized Official - Last Name:GONZALEZ
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:786-718-3739
Mailing Address - Street 1:7400 SW 50TH TER STE 203
Mailing Address - Street 2:
Mailing Address - City:MIAMI
Mailing Address - State:FL
Mailing Address - Zip Code:33155-4486
Mailing Address - Country:US
Mailing Address - Phone:786-534-8131
Mailing Address - Fax:786-534-8191
Practice Address - Street 1:7400 SW 50TH TER STE 203
Practice Address - Street 2:
Practice Address - City:MIAMI
Practice Address - State:FL
Practice Address - Zip Code:33155-4486
Practice Address - Country:US
Practice Address - Phone:786-534-8131
Practice Address - Fax:786-534-8191
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-06-19
Last Update Date:2021-07-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty