Healthcare Provider Details

I. General information

NPI: 1083139919
Provider Name (Legal Business Name): SOUTH BEACH ENDOCRINE WELLNESS LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/11/2017
Last Update Date: 11/04/2022
Certification Date: 08/18/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1380 NE MIAMI GARDENS DR STE 155
NORTH MIAMI BEACH FL
33179-4747
US

IV. Provider business mailing address

1380 NE MIAMI GARDENS DR STE 155
NORTH MIAMI BEACH FL
33179-4747
US

V. Phone/Fax

Practice location:
  • Phone: 305-431-2680
  • Fax: 305-901-6238
Mailing address:
  • Phone: 305-431-2680
  • Fax: 305-901-6238

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RE0101X
TaxonomyEndocrinology, Diabetes & Metabolism Physician
License NumberOS12010
License Number StateFL

VIII. Authorized Official

Name: DR. JEREMY SCOTT BLEICHER
Title or Position: CHAIRMAN
Credential: DO
Phone: 305-431-2680