Provider Demographics
NPI:1891359162
Name:THE MODEL MEDICAL GROUP
Entity Type:Organization
Organization Name:THE MODEL MEDICAL GROUP
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:DR
Authorized Official - First Name:ERICA
Authorized Official - Middle Name:MONICA
Authorized Official - Last Name:CREW
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:516-384-1134
Mailing Address - Street 1:2555 COX RD
Mailing Address - Street 2:
Mailing Address - City:COCOA
Mailing Address - State:FL
Mailing Address - Zip Code:32926-3525
Mailing Address - Country:US
Mailing Address - Phone:516-384-1134
Mailing Address - Fax:
Practice Address - Street 1:333 W COCOA BEACH CSWY STE D
Practice Address - Street 2:
Practice Address - City:COCOA BEACH
Practice Address - State:FL
Practice Address - Zip Code:32931-3513
Practice Address - Country:US
Practice Address - Phone:516-384-1134
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-04-23
Last Update Date:2019-04-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty