Basic Information
| Provider Information | |||||||||
| NPI: | 1346317039 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | UNIVERSITY OF MIAMI | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
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| Credential: | |||||||||
| OtherOrganizationName: | UMIAMI MEDICINE - OPHTHALMOLOGY (PALM BEACH BASCOM PALMER - ASC) | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 7103 FAIRWAY DR | ||||||||
| Address2: | |||||||||
| City: | PALM BEACH GARDENS | ||||||||
| State: | FL | ||||||||
| PostalCode: | 334183701 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5615151500 | ||||||||
| FaxNumber: | 3052438470 | ||||||||
| Practice Location | |||||||||
| Address1: | 7103 FAIRWAY DR | ||||||||
| Address2: | |||||||||
| City: | PALM BEACH GARDENS | ||||||||
| State: | FL | ||||||||
| PostalCode: | 334183701 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5615151500 | ||||||||
| FaxNumber: | 3052438470 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/29/2006 | ||||||||
| LastUpdateDate: | 12/31/2019 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | SANCHEZ | ||||||||
| AuthorizedOfficialFirstName: | CESIA | ||||||||
| AuthorizedOfficialMiddleName: | A | ||||||||
| AuthorizedOfficialTitleorPosition: | PROVIDER ENROLLMENT MANAGER | ||||||||
| AuthorizedOfficialTelephone: | 3052436837 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 12/31/2019 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QA1903X | 200706483 | FL | Y | Ambulatory Health Care Facilities | Clinic/Center | Ambulatory Surgical |
ID Information
| ID | Type | State | Issuer | Description | 0766534-00 | 05 | FL | MEDICAID |