Basic Information
| Provider Information | |||||||||
| NPI: | 1407091069 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | PROFESSIONAL HEALTH MANAGEMENT SERVICES | ||||||||
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| Mailing Information | |||||||||
| Address1: | 8260 W FLAGLER ST STE 2M | ||||||||
| Address2: | |||||||||
| City: | MIAMI | ||||||||
| State: | FL | ||||||||
| PostalCode: | 331442069 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3055594599 | ||||||||
| FaxNumber: | 3055530670 | ||||||||
| Practice Location | |||||||||
| Address1: | 8260 W FLAGLER ST STE 2M | ||||||||
| Address2: | |||||||||
| City: | MIAMI | ||||||||
| State: | FL | ||||||||
| PostalCode: | 331442069 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3055594599 | ||||||||
| FaxNumber: | 3055530670 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/11/2008 | ||||||||
| LastUpdateDate: | 12/11/2008 | ||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | PORTILLA | ||||||||
| AuthorizedOfficialFirstName: | GINNA | ||||||||
| AuthorizedOfficialMiddleName: | VIVIANA | ||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 7865472382 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MISS | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 302R00000X | 562061-3 | FL | Y | Managed Care Organizations | Health Maintenance Organization |
No ID Information.