MEDICARE: MIDLAND MEDICAL - MIAMI SHORES, INC.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	207QA0505X	Adult Medicine Physician	HCC6722	FL

General Provider Information

NPI Number	:	1548350259
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	MIDLAND MEDICAL - MIAMI SHORES, INC.

Provider Business Mailing Address
First Line	:	8642 NE 2ND AVE
Second Line	:
City	:	EL PORTAL
State	:	FL
Zip	:	33138-3004
Country	:	US
Telephone Number	:	305-751-9677
Fax Number	:	305-899-7120

Provider Business Practice Location Address
First Line	:	8642 NE 2ND AVE
Second Line	:
City	:	EL PORTAL
State	:	FL
Zip	:	33138-3004
Country	:	US
Telephone Number	:	305-751-9677
Fax Number	:	305-899-7120

Authorized Official
Title or Position	:	PRESIDENT
Name	:	MR. MALCOM ROY
Credential	:
Telephone Number	:	305-751-9677

Provider Enumeration Date	:	10/13/2006
Last Update Date	:	08/22/2020

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