Basic Information
| Provider Information | |||||||||
| NPI: | 1568038529 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | CONVIVA MEDICAL CENTER MANAGEMENT LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 6101 BLUE LAGOON DR STE 400 | ||||||||
| Address2: | |||||||||
| City: | MIAMI | ||||||||
| State: | FL | ||||||||
| PostalCode: | 331262051 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3055002000 | ||||||||
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| Practice Location | |||||||||
| Address1: | 4340 W HILLSBOROUGH AVE | ||||||||
| Address2: | |||||||||
| City: | TAMPA | ||||||||
| State: | FL | ||||||||
| PostalCode: | 336145560 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8134258970 | ||||||||
| FaxNumber: | 8134258925 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/01/2021 | ||||||||
| LastUpdateDate: | 06/01/2021 | ||||||||
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| AuthorizedOfficialLastName: | BURGOS | ||||||||
| AuthorizedOfficialFirstName: | OFELIA | ||||||||
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| AuthorizedOfficialTitleorPosition: | DIRECTOR | ||||||||
| AuthorizedOfficialTelephone: | 3055002000 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | CONVIVA MEDICAL CENTER MANAGEMENT LLC | ||||||||
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| NPICertificationDate: | 06/01/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Family Medicine | 208D00000X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | General Practice | 207R00000X | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine |
No ID Information.