Healthcare Provider Details

I. General information

NPI: 1144479007
Provider Name (Legal Business Name): NORTH MIAMI COLORECTAL SURGERY
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/16/2008
Last Update Date: 09/17/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

777 E 25TH ST SUITE409
HIALEAH FL
33013-3825
US

IV. Provider business mailing address

777 E 25TH ST SUITE409
HIALEAH FL
33013-3825
US

V. Phone/Fax

Practice location:
  • Phone: 305-696-0001
  • Fax: 305-696-0007
Mailing address:
  • Phone: 305-696-0001
  • Fax: 305-696-0007

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208600000X
TaxonomySurgery Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code208C00000X
TaxonomyColon & Rectal Surgery Physician
License Number
License Number State

VIII. Authorized Official

Name: DR. ROGER K PONS
Title or Position: MEMBER
Credential: MD
Phone: 305-696-0001