Healthcare Provider Details

I. General information

NPI: 1548350259
Provider Name (Legal Business Name): MIDLAND MEDICAL - MIAMI SHORES, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/13/2006
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8642 NE 2ND AVE
EL PORTAL FL
33138-3004
US

IV. Provider business mailing address

8642 NE 2ND AVE
EL PORTAL FL
33138-3004
US

V. Phone/Fax

Practice location:
  • Phone: 305-751-9677
  • Fax: 305-899-7120
Mailing address:
  • Phone: 305-751-9677
  • Fax: 305-899-7120

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207QA0505X
TaxonomyAdult Medicine Physician
License NumberHCC6722
License Number StateFL

VIII. Authorized Official

Name: MR. MALCOM ROY
Title or Position: PRESIDENT
Credential:
Phone: 305-751-9677