Healthcare Provider Details

I. General information

NPI: 1265866693
Provider Name (Legal Business Name): MGM MEDICAL GROUP MANAGEMENT LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/21/2013
Last Update Date: 08/21/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8318 SW 193RD ST
CUTLER BAY FL
33157-8085
US

IV. Provider business mailing address

8318 SW 193RD ST
CUTLER BAY FL
33157-8085
US

V. Phone/Fax

Practice location:
  • Phone: 786-395-1165
  • Fax:
Mailing address:
  • Phone: 786-395-1165
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code302F00000X
TaxonomyExclusive Provider Organization
License Number
License Number State

VIII. Authorized Official

Name: MR. MARIO ARMANDO ESPINO JR.
Title or Position: CEO/PRESIDENT
Credential:
Phone: 786-395-1165