Basic Information
| Provider Information | |||||||||
| NPI: | 1841369006 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | SOUTH DADE NEONATOLOGY | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 43-2620 | ||||||||
| Address2: | |||||||||
| City: | SOUTH MIAMI | ||||||||
| State: | FL | ||||||||
| PostalCode: | 332432620 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3054417179 | ||||||||
| FaxNumber: | 3054487134 | ||||||||
| Practice Location | |||||||||
| Address1: | 215 GRAND AVE | ||||||||
| Address2: | |||||||||
| City: | CORAL GABLES | ||||||||
| State: | FL | ||||||||
| PostalCode: | 331334841 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3054417179 | ||||||||
| FaxNumber: | 3054487134 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/06/2006 | ||||||||
| LastUpdateDate: | 01/27/2011 | ||||||||
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| AuthorizedOfficialLastName: | VALDES | ||||||||
| AuthorizedOfficialFirstName: | ERNESTO | ||||||||
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| AuthorizedOfficialTitleorPosition: | PARTNER | ||||||||
| AuthorizedOfficialTelephone: | 3054417179 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | MD | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2080N0001X | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Pediatrics | Neonatal-Perinatal Medicine |
ID Information
| ID | Type | State | Issuer | Description | 38734 | 01 | FL | BC BS | OTHER | 256644300 | 05 | FL | MEDICAID |