Healthcare Provider Details

I. General information

NPI: 1003746777
Provider Name (Legal Business Name): SUN GROVE MEDICAL GROUP PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/22/2026
Last Update Date: 05/22/2026
Certification Date: 05/22/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10339 SW 145TH CT
MIAMI FL
33186-6946
US

IV. Provider business mailing address

PO BOX 960183
MIAMI FL
33296-0183
US

V. Phone/Fax

Practice location:
  • Phone: 787-565-9062
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208D00000X
TaxonomyGeneral Practice Physician
License Number
License Number State

VIII. Authorized Official

Name: JORGE HERNANDEZ CANCIOBELLO
Title or Position: OWNER
Credential: MD
Phone: 787-565-9062