Healthcare Provider Details

I. General information

NPI: 1255223475
Provider Name (Legal Business Name): MSO HEALTH SYSTEM, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/21/2025
Last Update Date: 07/21/2025
Certification Date: 07/21/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4601 NW 77TH AVE
MIAMI FL
33166-6449
US

IV. Provider business mailing address

4601 NW 77TH AVE
MIAMI FL
33166-6449
US

V. Phone/Fax

Practice location:
  • Phone: 305-262-1292
  • Fax: 305-262-1292
Mailing address:
  • Phone: 305-262-1292
  • Fax: 305-262-1292

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code171M00000X
TaxonomyCase Manager/Care Coordinator
License Number
License Number State

VIII. Authorized Official

Name: ERIC MILLER
Title or Position: CHIEF COMPLIANCE OFFICER
Credential:
Phone: 305-262-1292