Healthcare Provider Details

I. General information

NPI: 1245658871
Provider Name (Legal Business Name): MIRRA MEDICAL GROUP LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/01/2014
Last Update Date: 04/01/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

15261 CORTEZ BLVD
BROOKSVILLE FL
34613-6072
US

IV. Provider business mailing address

15261 CORTEZ BLVD
BROOKSVILLE FL
34613-6072
US

V. Phone/Fax

Practice location:
  • Phone: 352-584-7452
  • Fax: 727-399-9037
Mailing address:
  • Phone: 352-584-7452
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number0018523
License Number StateFL

VIII. Authorized Official

Name: MR. MIRZA BIAG
Title or Position: VP - BUSINESS DEVELOPMENT
Credential:
Phone: 352-584-7452