Basic Information
| Provider Information | |||||||||
| NPI: | 1538372693 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | UNIVERSITY OF MIAMI | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | UMIAMI MEDICINE - PEDI EARLY STEP PROGRAM | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1120 NW 14 STREET (C208) - 12TH FLOOR - ROOM 1210 | ||||||||
| Address2: | CLINICAL RESEARCH BUILDING | ||||||||
| City: | MIAMI | ||||||||
| State: | FL | ||||||||
| PostalCode: | 33136 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3052436660 | ||||||||
| FaxNumber: | 3052433501 | ||||||||
| Practice Location | |||||||||
| Address1: | 1120 NW 14TH ST # C208 | ||||||||
| Address2: | 12TH FLOOR - ROOM 1210 | ||||||||
| City: | MIAMI | ||||||||
| State: | FL | ||||||||
| PostalCode: | 331362107 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3052436660 | ||||||||
| FaxNumber: | 3052433501 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/07/2007 | ||||||||
| LastUpdateDate: | 12/31/2019 | ||||||||
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| AuthorizedOfficialLastName: | SANCHEZ | ||||||||
| AuthorizedOfficialFirstName: | CESIA | ||||||||
| AuthorizedOfficialMiddleName: | A | ||||||||
| AuthorizedOfficialTitleorPosition: | PROVIDER ENROLLMENT MANAGER | ||||||||
| AuthorizedOfficialTelephone: | 3052436837 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| NPICertificationDate: | 12/31/2019 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QD1600X | Y | Ambulatory Health Care Facilities | Clinic/Center | Developmental Disabilities |
ID Information
| ID | Type | State | Issuer | Description | 750741101 | 05 | FL | MEDICAID |