Healthcare Provider Details

I. General information

NPI: 1225794852
Provider Name (Legal Business Name): CONSTELLATION MEDICAL GROUP LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/09/2021
Last Update Date: 02/09/2022
Certification Date: 02/09/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1850 NE 163RD ST
NORTH MIAMI BEACH FL
33162-4867
US

IV. Provider business mailing address

1205 SW 37TH AVE
MIAMI FL
33135-4226
US

V. Phone/Fax

Practice location:
  • Phone: 786-552-7800
  • Fax:
Mailing address:
  • Phone: 786-552-7800
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207QG0300X
TaxonomyGeriatric Medicine (Family Medicine) Physician
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code208D00000X
TaxonomyGeneral Practice Physician
License Number
License Number State

VIII. Authorized Official

Name: DR. NICOLAS ALVAREZ
Title or Position: CEO
Credential: MD
Phone: 786-552-7800