Provider Demographics
NPI:1942947346
Name:CONVIVA MEDICAL CENTER MANAGEMENT LLC
Entity Type:Organization
Organization Name:CONVIVA MEDICAL CENTER MANAGEMENT LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CREDENTIALING DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:OFELIA
Authorized Official - Middle Name:
Authorized Official - Last Name:BURGOS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:305-500-2000
Mailing Address - Street 1:6101 BLUE LAGOON DR STE 400
Mailing Address - Street 2:
Mailing Address - City:MIAMI
Mailing Address - State:FL
Mailing Address - Zip Code:33126-2051
Mailing Address - Country:US
Mailing Address - Phone:305-500-2000
Mailing Address - Fax:
Practice Address - Street 1:12177 PEMBROKE RD
Practice Address - Street 2:
Practice Address - City:PEMBROKE PINES
Practice Address - State:FL
Practice Address - Zip Code:33025-1727
Practice Address - Country:US
Practice Address - Phone:954-436-0555
Practice Address - Fax:954-436-0108
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:CONVIVA MEDICAL CENTER MANAGEMENT LLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2022-05-17
Last Update Date:2022-05-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
No207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty
No208D00000XAllopathic & Osteopathic PhysiciansGeneral PracticeGroup - Multi-Specialty