Provider Demographics
NPI:1902209497
Name:MDLIVE MEDICAL GROUP NM, LLC
Entity Type:Organization
Organization Name:MDLIVE MEDICAL GROUP NM, LLC
Other - Org Name:MDLIVE MEDICAL GROUP
Other - Org Type:Doing Business As
Authorized Official - Title/Position:SR. DIRECTOR PROVIDER SERVICES
Authorized Official - Prefix:
Authorized Official - First Name:MERRY
Authorized Official - Middle Name:
Authorized Official - Last Name:SCHUMACHER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:800-400-6354
Mailing Address - Street 1:13630 NW 8TH ST
Mailing Address - Street 2:SUITE 205
Mailing Address - City:SUNRISE
Mailing Address - State:FL
Mailing Address - Zip Code:33325-6238
Mailing Address - Country:US
Mailing Address - Phone:954-466-0593
Mailing Address - Fax:954-206-0800
Practice Address - Street 1:3350 SW 148TH AVE STE 300
Practice Address - Street 2:
Practice Address - City:MIRAMAR
Practice Address - State:FL
Practice Address - Zip Code:33027-3259
Practice Address - Country:US
Practice Address - Phone:800-400-6354
Practice Address - Fax:231-932-4133
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-09-29
Last Update Date:2023-06-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty
No207P00000XAllopathic & Osteopathic PhysiciansEmergency MedicineGroup - Multi-Specialty
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
No208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM24902021Medicaid