Provider Demographics
NPI:1649814393
Name:BMG OF FLORIDA PA
Entity type:Organization
Organization Name:BMG OF FLORIDA PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:QUOC
Authorized Official - Middle Name:
Authorized Official - Last Name:HA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:615-562-4048
Mailing Address - Street 1:23275 S POINTE DR STE 100
Mailing Address - Street 2:
Mailing Address - City:LAGUNA HILLS
Mailing Address - State:CA
Mailing Address - Zip Code:92653-1498
Mailing Address - Country:US
Mailing Address - Phone:615-562-4048
Mailing Address - Fax:
Practice Address - Street 1:106 BOSTON AVE STE 204
Practice Address - Street 2:
Practice Address - City:ALTAMONTE SPRINGS
Practice Address - State:FL
Practice Address - Zip Code:32701-4712
Practice Address - Country:US
Practice Address - Phone:615-562-4048
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-11-05
Last Update Date:2019-11-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208800000XAllopathic & Osteopathic PhysiciansUrologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL208800000XOtherUROLOGY