Provider Demographics
NPI:1710321252
Name:GROUP MEDICAL CLINIC INC
Entity Type:Organization
Organization Name:GROUP MEDICAL CLINIC INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:FAUSTO
Authorized Official - Middle Name:P
Authorized Official - Last Name:ASTILLO
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:305-603-9636
Mailing Address - Street 1:540 NW 165TH ST STE 302
Mailing Address - Street 2:
Mailing Address - City:MIAMI
Mailing Address - State:FL
Mailing Address - Zip Code:33169-6304
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:540 NW 165TH ST STE 302
Practice Address - Street 2:
Practice Address - City:MIAMI
Practice Address - State:FL
Practice Address - Zip Code:33169-6304
Practice Address - Country:US
Practice Address - Phone:305-603-9636
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-04-27
Last Update Date:2013-04-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral PracticeGroup - Single Specialty