Basic Information
| Provider Information | |||||||||
| NPI: | 1245658871 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | MIRRA MEDICAL GROUP LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 15261 CORTEZ BLVD | ||||||||
| Address2: | |||||||||
| City: | BROOKSVILLE | ||||||||
| State: | FL | ||||||||
| PostalCode: | 346136072 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3525847452 | ||||||||
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| Practice Location | |||||||||
| Address1: | 15261 CORTEZ BLVD | ||||||||
| Address2: | |||||||||
| City: | BROOKSVILLE | ||||||||
| State: | FL | ||||||||
| PostalCode: | 346136072 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3525847452 | ||||||||
| FaxNumber: | 7273999037 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/01/2014 | ||||||||
| LastUpdateDate: | 04/01/2014 | ||||||||
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| AuthorizedOfficialLastName: | BIAG | ||||||||
| AuthorizedOfficialFirstName: | MIRZA | ||||||||
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| AuthorizedOfficialTitleorPosition: | VP - BUSINESS DEVELOPMENT | ||||||||
| AuthorizedOfficialTelephone: | 3525847452 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MR. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | 0018523 | FL | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine |
No ID Information.