Basic Information
| Provider Information | |||||||||
| NPI: | 1871698027 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | FRAGA MEDICAL CENTER, INC. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 4141 SW 6TH ST | ||||||||
| Address2: | |||||||||
| City: | CORAL GABLES | ||||||||
| State: | FL | ||||||||
| PostalCode: | 331342057 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3054435031 | ||||||||
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| Practice Location | |||||||||
| Address1: | 11865 CORAL WAY | ||||||||
| Address2: | SUITE B-7 | ||||||||
| City: | MIAMI | ||||||||
| State: | FL | ||||||||
| PostalCode: | 331752400 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3052206128 | ||||||||
| FaxNumber: | 3052272855 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/13/2006 | ||||||||
| LastUpdateDate: | 03/17/2018 | ||||||||
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| AuthorizedOfficialLastName: | CASANOVA | ||||||||
| AuthorizedOfficialFirstName: | RENE | ||||||||
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| AuthorizedOfficialTitleorPosition: | MEDICAL DIRECTOR | ||||||||
| AuthorizedOfficialTelephone: | 9548167795 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | DR. | ||||||||
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| AuthorizedOfficialCredential: | MD | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | ACN961 | FL | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Family Medicine | 2080A0000X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Pediatrics | Adolescent Medicine | 208D00000X | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | General Practice |
ID Information
| ID | Type | State | Issuer | Description | 279234600 | 05 | FL | MEDICAID | 054135400 | 05 | FL | MEDICAID |