Healthcare Provider Details

I. General information

NPI: 1790121325
Provider Name (Legal Business Name): INTERAMERICAN MEDICAL CENTER GROUP LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/22/2013
Last Update Date: 08/15/2024
Certification Date: 08/15/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

15105 NW 77TH AVE
MIAMI LAKES FL
33014-7803
US

IV. Provider business mailing address

1000 NW 57TH CT STE 400
MIAMI FL
33126-3292
US

V. Phone/Fax

Practice location:
  • Phone: 305-649-8100
  • Fax: 305-649-8778
Mailing address:
  • Phone: 305-649-8100
  • Fax: 305-649-8778

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number
License Number State

VIII. Authorized Official

Name: CARLOS DE SOLO
Title or Position: CHIEF EXECUTIVE OFFICER
Credential:
Phone: 305-649-8100