Basic Information
| Provider Information | |||||||||
| NPI: | 1033159595 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | SOUTH MIAMI BLOOD FLOW ASSOCIATES LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 151 N. NOB HILL ROAD | ||||||||
| Address2: | SUITE 273 | ||||||||
| City: | PLANTATION | ||||||||
| State: | FL | ||||||||
| PostalCode: | 333241708 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7866628174 | ||||||||
| FaxNumber: | 3054412144 | ||||||||
| Practice Location | |||||||||
| Address1: | 6200 SW 73RD ST | ||||||||
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| City: | SOUTH MIAMI | ||||||||
| State: | FL | ||||||||
| PostalCode: | 331434679 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7866628174 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 06/06/2006 | ||||||||
| LastUpdateDate: | 11/22/2011 | ||||||||
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| AuthorizedOfficialLastName: | REISS | ||||||||
| AuthorizedOfficialFirstName: | IAN | ||||||||
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| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 3056681660 | ||||||||
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| 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 | 2085R0202X | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Radiology | Diagnostic Radiology |
ID Information
| ID | Type | State | Issuer | Description | 375546100 | 05 | FL | MEDICAID |