Provider Demographics
NPI:1679236566
Name:BLUELAKEPHYSICIAN GROUP
Entity Type:Organization
Organization Name:BLUELAKEPHYSICIAN GROUP
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEDICAL DIRECTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:TREVINE
Authorized Official - Middle Name:ROSHAN
Authorized Official - Last Name:ALBERT
Authorized Official - Suffix:I
Authorized Official - Credentials:OS14935
Authorized Official - Phone:916-225-6888
Mailing Address - Street 1:4800 W FLAGLER ST STE 212
Mailing Address - Street 2:
Mailing Address - City:CORAL GABLES
Mailing Address - State:FL
Mailing Address - Zip Code:33134-1401
Mailing Address - Country:US
Mailing Address - Phone:786-703-3195
Mailing Address - Fax:786-703-3195
Practice Address - Street 1:4800 W FLAGLER ST STE 212
Practice Address - Street 2:
Practice Address - City:CORAL GABLES
Practice Address - State:FL
Practice Address - Zip Code:33134-1401
Practice Address - Country:US
Practice Address - Phone:786-703-3195
Practice Address - Fax:786-703-3195
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-10-18
Last Update Date:2021-10-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/Center
No2251S0007XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistSportsGroup - Multi-Specialty