Basic Information
| Provider Information | |||||||||
| NPI: | 1245218197 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | MCH PEDIATRIC CARDIOLOGY,LLC | ||||||||
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| OtherOrganizationName: | MCH PEDIATRIC CARDIOLOGY,LLC | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 557367 | ||||||||
| Address2: | |||||||||
| City: | MIAMI | ||||||||
| State: | FL | ||||||||
| PostalCode: | 332557367 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3056628301 | ||||||||
| FaxNumber: | 3056628304 | ||||||||
| Practice Location | |||||||||
| Address1: | 50 W. STUTERVANT STREET | ||||||||
| Address2: | |||||||||
| City: | ORLANDO | ||||||||
| State: | FL | ||||||||
| PostalCode: | 32806 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4076496907 | ||||||||
| FaxNumber: | 4074812035 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/02/2006 | ||||||||
| LastUpdateDate: | 05/06/2008 | ||||||||
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| AuthorizedOfficialLastName: | ALFARO | ||||||||
| AuthorizedOfficialFirstName: | PEDRO | ||||||||
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| AuthorizedOfficialTitleorPosition: | SENIOR VP & CFO | ||||||||
| AuthorizedOfficialTelephone: | 3056666511 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MR. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2080P0202X | Y | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Pediatrics | Pediatric Cardiology |
ID Information
| ID | Type | State | Issuer | Description | 259873601 | 05 | FL | MEDICAID |