Provider Demographics
NPI:1871670489
Name:ISLAND CLINIC OF KEY BISCAYNE LLC
Entity Type:Organization
Organization Name:ISLAND CLINIC OF KEY BISCAYNE LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CHAIRMAN
Authorized Official - Prefix:
Authorized Official - First Name:CARMEN
Authorized Official - Middle Name:J
Authorized Official - Last Name:ORTIZ BUTCHER
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:305-365-8222
Mailing Address - Street 1:PO BOX 491433
Mailing Address - Street 2:
Mailing Address - City:KEY BISCAYNE
Mailing Address - State:FL
Mailing Address - Zip Code:33149-7433
Mailing Address - Country:US
Mailing Address - Phone:305-365-8222
Mailing Address - Fax:305-365-8299
Practice Address - Street 1:967 CRANDON BLVD
Practice Address - Street 2:
Practice Address - City:KEY BISCAYNE
Practice Address - State:FL
Practice Address - Zip Code:33149-2753
Practice Address - Country:US
Practice Address - Phone:305-365-8222
Practice Address - Fax:305-365-8299
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-01
Last Update Date:2007-10-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME0045129207RN0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RN0300XAllopathic & Osteopathic PhysiciansInternal MedicineNephrologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLD82654Medicare UPIN