MEDICARE: MIAMI BLU SKY MEDICAL CENTER 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	207R00000X	Internal Medicine Physician

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1851982169
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	MIAMI BLU SKY MEDICAL CENTER INC

Provider Business Mailing Address
First Line	:	85 GRAND CANAL DR STE 407
Second Line	:
City	:	MIAMI
State	:	FL
Zip	:	33144-2571
Country	:	US
Telephone Number	:	786-409-4379
Fax Number	:	786-409-4217

Provider Business Practice Location Address
First Line	:	85 GRAND CANAL DR STE 407
Second Line	:
City	:	MIAMI
State	:	FL
Zip	:	33144-2571
Country	:	US
Telephone Number	:	786-409-4379
Fax Number	:	786-409-4217

Authorized Official
Title or Position	:	PRESIDENT
Name	:	ALEXEIS GONZALEZ LACOSTA
Credential	:
Telephone Number	:	786-409-4379

Provider Enumeration Date	:	01/29/2021
Last Update Date	:	09/05/2023

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