Basic Information
| Provider Information | |||||||||
| NPI: | 1306898242 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | FERNANDEZ BLAY MD PA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 14143 SW 52ND ST | ||||||||
| Address2: | |||||||||
| City: | MIRAMAR | ||||||||
| State: | FL | ||||||||
| PostalCode: | 330275978 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3053228096 | ||||||||
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| Practice Location | |||||||||
| Address1: | 2488 N UNIVERSITY DR | ||||||||
| Address2: | |||||||||
| City: | PEMBROKE PINES | ||||||||
| State: | FL | ||||||||
| PostalCode: | 330243624 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9549839191 | ||||||||
| FaxNumber: | 3058291401 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/17/2006 | ||||||||
| LastUpdateDate: | 10/27/2008 | ||||||||
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| AuthorizedOfficialLastName: | FERNANDEZ BLAY | ||||||||
| AuthorizedOfficialFirstName: | ROBERTO | ||||||||
| AuthorizedOfficialMiddleName: | CARLOS | ||||||||
| AuthorizedOfficialTitleorPosition: | PRES/OWNER | ||||||||
| AuthorizedOfficialTelephone: | 3053228096 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | MD | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | ME93447 | FL | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine |
ID Information
| ID | Type | State | Issuer | Description | 274947500 | 05 | FL | MEDICAID |