Healthcare Provider Details

I. General information

NPI: 1609291368
Provider Name (Legal Business Name): NEUROINTERVENTIONAL CONSULTANTS, PA
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/04/2014
Last Update Date: 04/30/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

100 LINCOLN RD # 1403
MIAMI BEACH FL
33139-2013
US

IV. Provider business mailing address

100 LINCOLN RD # 1403
MIAMI BEACH FL
33139-2013
US

V. Phone/Fax

Practice location:
  • Phone: 210-287-7311
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2085N0700X
TaxonomyNeuroradiology Physician
License NumberME114714
License Number StateFL
# 2
Primary TaxonomyY
Taxonomy Code207T00000X
TaxonomyNeurological Surgery Physician
License NumberME114714
License Number StateFL

VIII. Authorized Official

Name: PATRICIA M FERNANDEZ
Title or Position: DIRECTOR / PRESIDENT
Credential: MD
Phone: 210-287-7311