Healthcare Provider Details

I. General information

NPI: 1912815754
Provider Name (Legal Business Name): MERIDIAN MEDICAL GROUP LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/01/2026
Last Update Date: 09/01/2026
Certification Date: 08/28/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9885 SW 123RD TERRACE
MIAMI FL
33176
US

IV. Provider business mailing address

13818 SW 152ND ST # 216
MIAMI FL
33177-1164
US

V. Phone/Fax

Practice location:
  • Phone: 305-396-1701
  • Fax: 645-231-2225
Mailing address:
  • Phone: 305-396-1701
  • Fax: 645-231-2225

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number
License Number State

VIII. Authorized Official

Name: STEPHAN DIMITRJEVITCH
Title or Position: MANAGING MEMBER
Credential: APRN, PMHNP
Phone: 305-396-1701