Healthcare Provider Details

I. General information

NPI: 1689807653
Provider Name (Legal Business Name): PRIMARY HEALTH HOSPITALIST OF SOUTH FLORIDA LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/25/2009
Last Update Date: 08/25/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1455 SW 27TH AVE
MIAMI FL
33145-1234
US

IV. Provider business mailing address

1455 SW 27TH AVE
MIAMI FL
33145-1234
US

V. Phone/Fax

Practice location:
  • Phone: 305-649-3260
  • Fax: 305-649-3261
Mailing address:
  • Phone: 305-649-3260
  • Fax: 305-649-3261

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207QA0505X
TaxonomyAdult Medicine Physician
License NumberME46299
License Number StateFL

VIII. Authorized Official

Name: DR. RAUL IGNACIO TANO
Title or Position: PRESIDENT
Credential: M.D.
Phone: 305-649-3260