Basic Information
| Provider Information | |||||||||
| NPI: | 1932366168 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | MCH PEDIATRIC CARDIOLOGY LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 557367 | ||||||||
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| City: | MIAMI | ||||||||
| State: | FL | ||||||||
| PostalCode: | 332557367 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3056666511 | ||||||||
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| Practice Location | |||||||||
| Address1: | 17615 SW 97TH AVE | ||||||||
| Address2: | |||||||||
| City: | VILLAGE OF PALMETTO BAY | ||||||||
| State: | FL | ||||||||
| PostalCode: | 331575636 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3056666511 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 05/16/2008 | ||||||||
| LastUpdateDate: | 05/16/2008 | ||||||||
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| AuthorizedOfficialLastName: | ALFARO | ||||||||
| AuthorizedOfficialFirstName: | PEDRO | ||||||||
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| AuthorizedOfficialTitleorPosition: | SENIOR VP & CFO | ||||||||
| AuthorizedOfficialTelephone: | 3056666511 | ||||||||
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| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | MCH PEDIATRIC CARDIOLOGY LLC | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2080P0202X | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Pediatrics | Pediatric Cardiology |
ID Information
| ID | Type | State | Issuer | Description | 259873607 | 05 | FL | MEDICAID |