Healthcare Provider Details

I. General information

NPI: 1841354883
Provider Name (Legal Business Name): COMMUNITY MEDICAL GROUP
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/21/2006
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4765 W 8TH AVE
HIALEAH FL
33012-3554
US

IV. Provider business mailing address

4765 W 8TH AVE
HIALEAH FL
33012-3554
US

V. Phone/Fax

Practice location:
  • Phone: 305-825-3834
  • Fax: 305-825-3834
Mailing address:
  • Phone: 305-825-3834
  • Fax: 305-825-3834

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code204C00000X
TaxonomySports Medicine (Neuromusculoskeletal Medicine) Physician
License NumberHCC5975
License Number StateFL

VIII. Authorized Official

Name: MARIA MORALES
Title or Position: PRESIDENT
Credential:
Phone: 305-825-3834