Basic Information
| Provider Information | |||||||||
| NPI: | 1316198583 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | INTERAMERICAN MEDICAL CENTER GROUP LLC | ||||||||
| LastName: | |||||||||
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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: | 5378 W 16 AVE | ||||||||
| Address2: | |||||||||
| City: | HIALEAH | ||||||||
| State: | FL | ||||||||
| PostalCode: | 330124300 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3058204101 | ||||||||
| FaxNumber: | 3058202885 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/07/2008 | ||||||||
| LastUpdateDate: | 09/21/2018 | ||||||||
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| AuthorizedOfficialLastName: | LAMOREAUX | ||||||||
| AuthorizedOfficialFirstName: | BILL | ||||||||
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| AuthorizedOfficialTitleorPosition: | CEO | ||||||||
| AuthorizedOfficialTelephone: | 3056498100 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MR. | ||||||||
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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 | 008705001 | 05 | FL | MEDICAID | EU039B | 01 | FL | PTAN | OTHER |