Healthcare Provider Details

I. General information

NPI: 1013340637
Provider Name (Legal Business Name): MEDAMAX MSO, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/19/2013
Last Update Date: 08/19/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

12555 BISCAYNE BLVD SUITE 480
NORTH MIAMI FL
33181-2522
US

IV. Provider business mailing address

12555 BISCAYNE BLVD SUITE 480
NORTH MIAMI FL
33181-2522
US

V. Phone/Fax

Practice location:
  • Phone: 305-733-3577
  • Fax: 305-933-1021
Mailing address:
  • Phone: 305-733-3577
  • Fax: 305-933-1021

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code171W00000X
TaxonomyContractor
License Number
License Number State

VIII. Authorized Official

Name: MR. ALAN DORNE
Title or Position: PRESIDENT
Credential:
Phone: 305-733-3577