Provider Demographics
NPI:1649725029
Name:SANTURCE MEDICAL CENTER LLC
Entity type:Organization
Organization Name:SANTURCE MEDICAL CENTER LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MD/CEO
Authorized Official - Prefix:DR
Authorized Official - First Name:ORLANDO
Authorized Official - Middle Name:E
Authorized Official - Last Name:MIELES
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:813-651-0005
Mailing Address - Street 1:500 VONDERBURG DR
Mailing Address - Street 2:SUITE 305
Mailing Address - City:BRANDON
Mailing Address - State:FL
Mailing Address - Zip Code:33511-5964
Mailing Address - Country:US
Mailing Address - Phone:813-624-9399
Mailing Address - Fax:
Practice Address - Street 1:500 VONDERBURG DR STE 305
Practice Address - Street 2:
Practice Address - City:BRANDON
Practice Address - State:FL
Practice Address - Zip Code:33511-5976
Practice Address - Country:US
Practice Address - Phone:813-651-0005
Practice Address - Fax:813-902-7234
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-08-16
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral PracticeGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL1700149143Medicaid