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General NPI Number Information
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NPI Number | 1003746777
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Entity Type | Organization
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Legal Business Name | SUN GROVE MEDICAL GROUP PLLC
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Dates
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Enumeration Date | 05/22/2026
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Last Update Date | 05/22/2026
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Provider Practice Location Address
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Address Line | 10339 SW 145TH CT
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City | MIAMI
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State | FL
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Zip | 33186-6946
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Country | US
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Telephone | 787-565-9062
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Fax |
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Provider Business Mailing Address
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Address Line | PO BOX 960183
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City | MIAMI
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State | FL
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Zip | 33296-0183
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Country | US
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Telephone |
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Fax |
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Authorized Official
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Title or Position | OWNER
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Name | JORGE HERNANDEZ CANCIOBELLO
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Credential | MD
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Telephone | 787-565-9062
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 208D00000X
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Taxonomy Name | General Practice Physician
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License Number |
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License Number State |
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