Basic Information
| Provider Information | |||||||||
| NPI: | 1356017743 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | PUBLIC HEALTH TRUST OF DADE COUNTY FLORIDA | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | JMG SPECIALTY PHYSICIANS | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 12493 | ||||||||
| Address2: | |||||||||
| City: | MIAMI | ||||||||
| State: | FL | ||||||||
| PostalCode: | 331012493 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3055855315 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 1801 NW 9TH AVE FL 2 | ||||||||
| Address2: | |||||||||
| City: | MIAMI | ||||||||
| State: | FL | ||||||||
| PostalCode: | 331361101 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7864668490 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/17/2021 | ||||||||
| LastUpdateDate: | 02/25/2022 | ||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | KNIGHT | ||||||||
| AuthorizedOfficialFirstName: | MARK | ||||||||
| AuthorizedOfficialMiddleName: | T | ||||||||
| AuthorizedOfficialTitleorPosition: | EXECUTIVE VP, CFO | ||||||||
| AuthorizedOfficialTelephone: | 3055858490 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | CFO | ||||||||
| NPICertificationDate: | 02/25/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208D00000X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | General Practice | 208000000X | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Pediatrics |
ID Information
| ID | Type | State | Issuer | Description | 000957213 | 05 | FL | MEDICAID |