Provider Demographics
NPI:1942927231
Name:BLUE MEDICI CORPORATION
Entity Type:Organization
Organization Name:BLUE MEDICI CORPORATION
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:LUIS
Authorized Official - Middle Name:
Authorized Official - Last Name:HERNANDEZ ROSADO
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:787-902-2594
Mailing Address - Street 1:12780 SW 71ST AVE
Mailing Address - Street 2:
Mailing Address - City:PINECREST
Mailing Address - State:FL
Mailing Address - Zip Code:33156-6239
Mailing Address - Country:US
Mailing Address - Phone:787-902-2594
Mailing Address - Fax:305-470-1853
Practice Address - Street 1:12780 SW 71ST AVE
Practice Address - Street 2:
Practice Address - City:PINECREST
Practice Address - State:FL
Practice Address - Zip Code:33156-6239
Practice Address - Country:US
Practice Address - Phone:787-902-2594
Practice Address - Fax:305-470-1853
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-10-26
Last Update Date:2022-11-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL1144527466OtherINDIVIDUAL NPI