Provider Demographics
NPI:1669504767
Name:CPC MEDICAL CENTER AT MILLER DRIVE, INC.
Entity Type:Organization
Organization Name:CPC MEDICAL CENTER AT MILLER DRIVE, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:VICE PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:RICHARD
Authorized Official - Middle Name:
Authorized Official - Last Name:CHERVONY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:305-854-6661
Mailing Address - Street 1:2455 SW 27TH AVE
Mailing Address - Street 2:SUITE 100
Mailing Address - City:MIAMI
Mailing Address - State:FL
Mailing Address - Zip Code:33145-3663
Mailing Address - Country:US
Mailing Address - Phone:305-854-6661
Mailing Address - Fax:305-856-6954
Practice Address - Street 1:10240 SW 56TH ST
Practice Address - Street 2:SUITE #106
Practice Address - City:MIAMI
Practice Address - State:FL
Practice Address - Zip Code:33165-7071
Practice Address - Country:US
Practice Address - Phone:305-598-8805
Practice Address - Fax:305-598-8109
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-12
Last Update Date:2012-12-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral PracticeGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLK3791Medicare ID - Type Unspecified