Healthcare Provider Details

I. General information

NPI: 1316684723
Provider Name (Legal Business Name): CONVIVA MEDICAL CENTER MANAGEMENT LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/17/2022
Last Update Date: 05/20/2024
Certification Date: 05/20/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

480 N STATE ROAD 7
PLANTATION FL
33317-2834
US

IV. Provider business mailing address

6101 BLUE LAGOON DR STE 400
MIAMI FL
33126-2051
US

V. Phone/Fax

Practice location:
  • Phone: 954-791-9580
  • Fax: 954-797-0473
Mailing address:
  • Phone: 305-500-2000
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code208D00000X
TaxonomyGeneral Practice Physician
License Number
License Number State

VIII. Authorized Official

Name: KEVIN MERIWETHER
Title or Position: PRESIDENT
Credential:
Phone: 305-500-2000