Basic Information
| Provider Information | |||||||||
| NPI: | 1639561418 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | METCARE OF FLORIDA | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | METCARE OF OKEECHOBEE | ||||||||
| 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: | 208 NE 19TH DR | ||||||||
| Address2: | |||||||||
| City: | OKEECHOBEE | ||||||||
| State: | FL | ||||||||
| PostalCode: | 349721932 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8637636431 | ||||||||
| FaxNumber: | 8637632319 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/03/2015 | ||||||||
| LastUpdateDate: | 06/10/2016 | ||||||||
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| AuthorizedOfficialLastName: | ROSELLO | ||||||||
| AuthorizedOfficialFirstName: | GEMMA | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | VP OPERATIONS | ||||||||
| AuthorizedOfficialTelephone: | 3055002000 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | HUMANA INC. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | Y | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | CX415A | 01 | FL | MEDICARE NUMBER | OTHER |