Basic Information
| Provider Information | |||||||||
| NPI: | 1417179599 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | CRITICAL CARE CONSULTANTS PA | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 160417 | ||||||||
| Address2: | |||||||||
| City: | MIAMI | ||||||||
| State: | FL | ||||||||
| PostalCode: | 331160417 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3054369933 | ||||||||
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| Practice Location | |||||||||
| Address1: | 3663 S MIAMI AVE | ||||||||
| Address2: | |||||||||
| City: | MIAMI | ||||||||
| State: | FL | ||||||||
| PostalCode: | 331334253 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3054369933 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 05/02/2007 | ||||||||
| LastUpdateDate: | 03/28/2018 | ||||||||
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| AuthorizedOfficialLastName: | MOAS | ||||||||
| AuthorizedOfficialFirstName: | CARLOS | ||||||||
| AuthorizedOfficialMiddleName: | M | ||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 3058540616 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | DR. | ||||||||
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| AuthorizedOfficialCredential: | M.D. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207RC0200X | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine | Critical Care Medicine |
ID Information
| ID | Type | State | Issuer | Description | 379264100 | 05 | FL | MEDICAID |