Basic Information
| Provider Information | |||||||||
| NPI: | 1396763934 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | CONTINUCARE MEDICAL MANAGEMENT, INC. | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
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| OtherOrganizationName: | CONTINUCARE MEDICAL CENTER | ||||||||
| OtherOrganizationType: | 5 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 7200 CORPORATE CENTER DR | ||||||||
| Address2: | SUITE 600 | ||||||||
| City: | MIAMI | ||||||||
| State: | FL | ||||||||
| PostalCode: | 331261200 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3055002009 | ||||||||
| FaxNumber: | 3055002145 | ||||||||
| Practice Location | |||||||||
| Address1: | 200 S MACDILL AVE | ||||||||
| Address2: | SUITE 100 | ||||||||
| City: | TAMPA | ||||||||
| State: | FL | ||||||||
| PostalCode: | 336093131 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8138372814 | ||||||||
| FaxNumber: | 8138394336 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/18/2006 | ||||||||
| LastUpdateDate: | 10/30/2014 | ||||||||
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| AuthorizedOfficialLastName: | ROSELLO | ||||||||
| AuthorizedOfficialFirstName: | GEMMA | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | VICE PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 3055002000 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 332900000X | N | Suppliers | Non-Pharmacy Dispensing Site | 261QM1300X | HCC 5466 | FL | Y | Ambulatory Health Care Facilities | Clinic/Center | Multi-Specialty |
ID Information
| ID | Type | State | Issuer | Description | 001887109 | 05 | FL | MEDICAID |