Healthcare Provider Details

I. General information

NPI: 1689327074
Provider Name (Legal Business Name): INDEPENDENT MEDICAL GROUP, LLC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/27/2022
Last Update Date: 09/28/2023
Certification Date: 09/28/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3880 COCONUT CREEK PKWY STE 100
COCONUT CREEK FL
33066-1643
US

IV. Provider business mailing address

5701 NW 88TH AVE STE 390
TAMARAC FL
33321-4451
US

V. Phone/Fax

Practice location:
  • Phone: 407-312-7392
  • Fax:
Mailing address:
  • Phone: 407-860-0283
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RI0200X
TaxonomyInfectious Disease Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code261QH0100X
TaxonomyHealth Service Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: SONIA N TORRES
Title or Position: CLINICAL OPERATIONS MANAGER
Credential:
Phone: 407-505-6435