Healthcare Provider Details

I. General information

NPI: 1619321684
Provider Name (Legal Business Name): MIVIP ANESTHESIA GROUP LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/15/2016
Last Update Date: 07/21/2022
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11801 SW 90TH ST SUITE 202
MIAMI FL
33186-2182
US

IV. Provider business mailing address

398 CAMINO GARDENS BLVD SUITE 102
BOCA RATON FL
33432-5827
US

V. Phone/Fax

Practice location:
  • Phone: 305-595-6850
  • Fax:
Mailing address:
  • Phone: 561-392-3341
  • Fax: 561-392-3793

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QH0100X
TaxonomyHealth Service Clinic/Center
License Number
License Number StateFL

VIII. Authorized Official

Name: DR. ISAAC VERBUKH
Title or Position: SOLE MBR
Credential:
Phone: 561-392-3341