Healthcare Provider Details

I. General information

NPI: 1184872178
Provider Name (Legal Business Name): PHYSICIAN ACCESS GROUP, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/03/2008
Last Update Date: 04/08/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

655 NW 119TH ST
NORTH MIAMI FL
33168-2522
US

IV. Provider business mailing address

655 NW 119TH ST
NORTH MIAMI FL
33168-2522
US

V. Phone/Fax

Practice location:
  • Phone: 305-403-2219
  • Fax: 786-517-3391
Mailing address:
  • Phone: 305-403-2219
  • Fax: 786-517-3391

VI. Provider taxonomy

Scope of Practice (Provider specialty)

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

VIII. Authorized Official

Name: DR. RUDOLPH MOISE
Title or Position: PRESIDENT/CEO
Credential: D.O.
Phone: 305-403-2219