Basic Information
| Provider Information | |||||||||
| NPI: | 1659088052 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | CONVIVA MEDICAL CENTER MANAGEMENT LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 6101 BLUE LAGOON DR STE 200 | ||||||||
| Address2: | |||||||||
| City: | MIAMI | ||||||||
| State: | FL | ||||||||
| PostalCode: | 331263168 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3055002000 | ||||||||
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| Practice Location | |||||||||
| Address1: | 2020 NE 48TH CT | ||||||||
| Address2: | |||||||||
| City: | FORT LAUDERDALE | ||||||||
| State: | FL | ||||||||
| PostalCode: | 333084522 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9546371168 | ||||||||
| FaxNumber: | 9545681330 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/04/2022 | ||||||||
| LastUpdateDate: | 11/04/2022 | ||||||||
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| AuthorizedOfficialLastName: | BONETTI | ||||||||
| AuthorizedOfficialFirstName: | JESSICA | ||||||||
| AuthorizedOfficialMiddleName: | MARIE | ||||||||
| AuthorizedOfficialTitleorPosition: | MANAGER | ||||||||
| AuthorizedOfficialTelephone: | 7865078556 | ||||||||
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| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | CONVIVA MEDICAL CENTER MANAGEMENT LLC | ||||||||
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| NPICertificationDate: | 11/01/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | N | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Family Medicine | 208D00000X | N | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | General Practice | 207R00000X | Y | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine |
No ID Information.