Healthcare Provider Details

I. General information

NPI: 1154284131
Provider Name (Legal Business Name): SELENE MEDICAL GROUP, P.A.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/05/2025
Last Update Date: 12/05/2025
Certification Date: 11/23/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

454 NE 93RD ST.
MIAMI FL
33138
US

IV. Provider business mailing address

11166 FAIRFAX BLVD STE 500
FAIRFAX VA
22030-5017
US

V. Phone/Fax

Practice location:
  • Phone: 804-214-6604
  • Fax:
Mailing address:
  • Phone: 804-214-6604
  • Fax: 571-701-2769

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207QS1201X
TaxonomySleep Medicine (Family Medicine) Physician
License Number
License Number State

VIII. Authorized Official

Name: ZACHARY ADAMS
Title or Position: PRESIDENT
Credential:
Phone: 804-214-6604