Provider Demographics
NPI:1669991873
Name:HERNANDEZ MEDICAL GROUP LLC
Entity type:Organization
Organization Name:HERNANDEZ MEDICAL GROUP LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:MEDICAL DOCTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:EMMANUEL
Authorized Official - Middle Name:
Authorized Official - Last Name:HERNANDEZ
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:305-900-8170
Mailing Address - Street 1:165 CAMERON DR
Mailing Address - Street 2:
Mailing Address - City:WESTON
Mailing Address - State:FL
Mailing Address - Zip Code:33326-3514
Mailing Address - Country:US
Mailing Address - Phone:305-900-8170
Mailing Address - Fax:
Practice Address - Street 1:2001 W 68TH ST
Practice Address - Street 2:
Practice Address - City:HIALEAH
Practice Address - State:FL
Practice Address - Zip Code:33016-1801
Practice Address - Country:US
Practice Address - Phone:305-823-5000
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-09-19
Last Update Date:2017-09-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLOS12178207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL1134418668OtherNPI INDIVIDUAL
FL012315900Medicaid