Provider Demographics
NPI:1962457929
Name:RAFAEL PELEGRIN M.D,MEDICAL GRP, LLC
Entity Type:Organization
Organization Name:RAFAEL PELEGRIN M.D,MEDICAL GRP, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:RAFAEL
Authorized Official - Middle Name:A
Authorized Official - Last Name:PELEGRIN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:205-279-1929
Mailing Address - Street 1:10661 SW 88TH ST
Mailing Address - Street 2:SUITE 113
Mailing Address - City:MIAMI
Mailing Address - State:FL
Mailing Address - Zip Code:33176-1550
Mailing Address - Country:US
Mailing Address - Phone:305-279-1929
Mailing Address - Fax:305-279-1935
Practice Address - Street 1:10661 SW 88TH ST
Practice Address - Street 2:SUITE 113
Practice Address - City:MIAMI
Practice Address - State:FL
Practice Address - Zip Code:33176-1550
Practice Address - Country:US
Practice Address - Phone:305-279-1929
Practice Address - Fax:305-279-1935
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-24
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL261Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/Center
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLK6134Medicare ID - Type Unspecified