Healthcare Provider Details

I. General information

NPI: 1275361982
Provider Name (Legal Business Name): MGH MEDICAL GROUP KS, PA
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/24/2024
Last Update Date: 07/24/2024
Certification Date: 07/24/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

515 S FEDERAL HWY
DEERFIELD BEACH FL
33441-4109
US

IV. Provider business mailing address

530 S FEDERAL HWY
DEERFIELD BEACH FL
33441-4140
US

V. Phone/Fax

Practice location:
  • Phone: 954-667-5465
  • Fax: 412-451-8656
Mailing address:
  • Phone: 954-667-5465
  • Fax: 412-451-8656

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code103TF0000X
TaxonomyFamily Psychologist
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code103TP2701X
TaxonomyGroup Psychotherapy Psychologist
License Number
License Number State
# 4
Primary TaxonomyY
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License Number
License Number State

VIII. Authorized Official

Name: GEMINISA M SOLORZANO
Title or Position: CRCO-RCM DIRECTOR
Credential:
Phone: 954-667-5465