Basic Information
| Provider Information | |||||||||
| NPI: | 1285872978 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | AMERICAN ACCESS CARE OF MIAMI, LLC | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
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| Credential: | |||||||||
| OtherOrganizationName: | AZURA VASCULAR CARE MIAMI | ||||||||
| OtherOrganizationType: | 3 | ||||||||
| OtherLastName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 415549 | ||||||||
| Address2: | |||||||||
| City: | BOSTON | ||||||||
| State: | MA | ||||||||
| PostalCode: | 022415549 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6106448900 | ||||||||
| FaxNumber: | 4849240053 | ||||||||
| Practice Location | |||||||||
| Address1: | 9200 S. DADELAND BLVD | ||||||||
| Address2: | SUITE 101, DADELAND TOWERS NORTH | ||||||||
| City: | MIAMI | ||||||||
| State: | FL | ||||||||
| PostalCode: | 331562703 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3056701044 | ||||||||
| FaxNumber: | 3056701046 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/03/2009 | ||||||||
| LastUpdateDate: | 08/12/2021 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | MILLER | ||||||||
| AuthorizedOfficialFirstName: | GREGG | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | AUTHORIZED OFFICIAL | ||||||||
| AuthorizedOfficialTelephone: | 7183691444 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | MD | ||||||||
| NPICertificationDate: | 08/12/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2085R0204X | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Radiology | Vascular & Interventional Radiology |
ID Information
| ID | Type | State | Issuer | Description | 001079100 | 05 | FL | MEDICAID |