Provider Demographics
NPI:1982870143
Name:CORAL REEF MEDICAL GROUP LLC
Entity Type:Organization
Organization Name:CORAL REEF MEDICAL GROUP LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:ROBERT
Authorized Official - Middle Name:
Authorized Official - Last Name:BLANCO
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:786-243-0149
Mailing Address - Street 1:30334 OLD DIXIE HWY
Mailing Address - Street 2:
Mailing Address - City:HOMESTEAD
Mailing Address - State:FL
Mailing Address - Zip Code:33033-3215
Mailing Address - Country:US
Mailing Address - Phone:786-243-0149
Mailing Address - Fax:786-234-2612
Practice Address - Street 1:30334 OLD DIXIE HWY
Practice Address - Street 2:
Practice Address - City:HOMESTEAD
Practice Address - State:FL
Practice Address - Zip Code:33033-3215
Practice Address - Country:US
Practice Address - Phone:786-243-0149
Practice Address - Fax:786-234-2612
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-05-07
Last Update Date:2013-03-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLARNP619302207Q00000X
FLPA9103866207Q00000X
FLME57421207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty
No207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLBD867Medicare UPIN