Basic Information
| Provider Information | |||||||||
| NPI: | 1316186984 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | CONTINUCARE MDHC, LLC | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | CONTINUCARE MEDICAL CENTER | ||||||||
| OtherOrganizationType: | 5 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 6101 BLUE LAGOON DR | ||||||||
| Address2: | SUITE 400 | ||||||||
| City: | MIAMI | ||||||||
| State: | FL | ||||||||
| PostalCode: | 331262055 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3055002114 | ||||||||
| FaxNumber: | 3053706024 | ||||||||
| Practice Location | |||||||||
| Address1: | 442 WASHINGTON AVE | ||||||||
| Address2: | |||||||||
| City: | HOMESTEAD | ||||||||
| State: | FL | ||||||||
| PostalCode: | 330306036 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3052450200 | ||||||||
| FaxNumber: | 3056311362 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/05/2009 | ||||||||
| LastUpdateDate: | 01/22/2020 | ||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | ROSELLO | ||||||||
| AuthorizedOfficialFirstName: | GEMMA | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | VICE PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 3055002000 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 01/22/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QM1300X | HCC 5545 | FL | Y | Ambulatory Health Care Facilities | Clinic/Center | Multi-Specialty |
ID Information
| ID | Type | State | Issuer | Description | 000563006 | 05 | FL | MEDICAID |