Basic Information
| Provider Information | |||||||||
| NPI: | 1063624799 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | CARRION UROLOGICAL CENTER, INC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1321 NW 14TH ST | ||||||||
| Address2: | SUITE 600 | ||||||||
| City: | MIAMI | ||||||||
| State: | FL | ||||||||
| PostalCode: | 331251673 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3055472534 | ||||||||
| FaxNumber: | 3053267210 | ||||||||
| Practice Location | |||||||||
| Address1: | 1321 NW 14TH ST | ||||||||
| Address2: | SUITE 600 | ||||||||
| City: | MIAMI | ||||||||
| State: | FL | ||||||||
| PostalCode: | 331251673 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3055472534 | ||||||||
| FaxNumber: | 3053267210 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/04/2007 | ||||||||
| LastUpdateDate: | 03/10/2013 | ||||||||
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| AuthorizedOfficialLastName: | CARRION | ||||||||
| AuthorizedOfficialFirstName: | HERNAN | ||||||||
| AuthorizedOfficialMiddleName: | MIGUEL | ||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 3055472534 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | DR. | ||||||||
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| AuthorizedOfficialCredential: | MD | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 174400000X | ME20544 | FL | Y | 193400000X SINGLE SPECIALTY GROUP | Other Service Providers | Specialist |
ID Information
| ID | Type | State | Issuer | Description | 053422600 | 05 | FL | MEDICAID |