Provider Demographics
NPI:1972536571
Name:MEDICAL GROUP OF FLORIDA INC
Entity Type:Organization
Organization Name:MEDICAL GROUP OF FLORIDA INC
Other - Org Name:MEDICAL GROUP OF FL
Other - Org Type:Former Legal Business Name
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:DR
Authorized Official - First Name:JULIAN
Authorized Official - Middle Name:
Authorized Official - Last Name:NODARSE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:305-285-4243
Mailing Address - Street 1:831 SW 14TH AVE
Mailing Address - Street 2:SUITE A
Mailing Address - City:MIAMI
Mailing Address - State:FL
Mailing Address - Zip Code:33135-5202
Mailing Address - Country:US
Mailing Address - Phone:305-285-4243
Mailing Address - Fax:305-285-4244
Practice Address - Street 1:831 SW 14TH AVE
Practice Address - Street 2:SUITE A
Practice Address - City:MIAMI
Practice Address - State:FL
Practice Address - Zip Code:33135-5202
Practice Address - Country:US
Practice Address - Phone:305-285-4243
Practice Address - Fax:305-285-4244
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-08
Last Update Date:2007-07-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME28764207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLK5101Medicare ID - Type Unspecified
FL78517AMedicare ID - Type Unspecified