Provider Demographics
NPI:1679758817
Name:MIAMI LAKES MEDICAL CENTER ASSOCIATES, P.A.
Entity Type:Organization
Organization Name:MIAMI LAKES MEDICAL CENTER ASSOCIATES, P.A.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:BRIAN
Authorized Official - Middle Name:A
Authorized Official - Last Name:ZALIS
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:305-821-6600
Mailing Address - Street 1:7150 W 20TH AVE
Mailing Address - Street 2:SUITE 315
Mailing Address - City:HIALEAH
Mailing Address - State:FL
Mailing Address - Zip Code:33016-5529
Mailing Address - Country:US
Mailing Address - Phone:305-821-6600
Mailing Address - Fax:305-821-0773
Practice Address - Street 1:7150 W 20TH AVE
Practice Address - Street 2:SUITE 315
Practice Address - City:HIALEAH
Practice Address - State:FL
Practice Address - Zip Code:33016-5529
Practice Address - Country:US
Practice Address - Phone:305-821-6600
Practice Address - Fax:305-821-0773
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-01-07
Last Update Date:2010-03-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME31692207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL000901OtherNHP KOBY
FL039823300Medicaid
FL170130OtherHUMANA
FL02704OtherMCR KOBY
FL4337911OtherAETNA KOBY
FL001729OtherNHP ZALIS
FL4521008OtherAETNA ZALIS
FL6972300OtherJMH ZALIS
FL7900000OtherJMH KOBY
FL79162OtherMCR ZALIS
FL014686OtherAVMED KOBY
FL02704OtherBCBS KOBY
FL044892300Medicaid
FL265997OtherAVMED ZALIS
FL79162OtherBCBS ZALIS
FL7900000OtherJMH KOBY
FL000901OtherNHP KOBY
FL02704OtherMCR KOBY