Basic Information
| Provider Information | |||||||||
| NPI: | 1275606832 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | INTERAMERICAN MEDICAL CENTER GROUP LLC | ||||||||
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| OtherOrganizationName: | IMC HEALTH | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1000 NW 57TH CT STE 200 | ||||||||
| Address2: | |||||||||
| City: | MIAMI | ||||||||
| State: | FL | ||||||||
| PostalCode: | 331263284 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3056498100 | ||||||||
| FaxNumber: | 3056498778 | ||||||||
| Practice Location | |||||||||
| Address1: | 1435 NE 8TH ST | ||||||||
| Address2: | |||||||||
| City: | HOMESTEAD | ||||||||
| State: | FL | ||||||||
| PostalCode: | 330334506 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3052463864 | ||||||||
| FaxNumber: | 3052461897 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/15/2006 | ||||||||
| LastUpdateDate: | 09/24/2018 | ||||||||
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| AuthorizedOfficialLastName: | LAMOREAUX | ||||||||
| AuthorizedOfficialFirstName: | BILL | ||||||||
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| AuthorizedOfficialTitleorPosition: | CEO | ||||||||
| AuthorizedOfficialTelephone: | 3056498100 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | EU039B | 01 | FL | PTAN | OTHER | 008705007 | 05 | FL | MEDICAID |