=====================================================
General NPI Number Information
=====================================================
NPI Number | 1013691070
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | MD MAX HEALTHCARE CORP
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/12/2023
-----------------------------------------------------
Last Update Date | 06/12/2023
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 3421 SW 107TH AVE
-----------------------------------------------------
City | MIAMI
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33165-3632
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 305-934-1160
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 3421 SW 107TH AVE
-----------------------------------------------------
City | MIAMI
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33165-3632
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 305-934-1160
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | P
-----------------------------------------------------
Name | JORGE E SANDELIS PEREZ
-----------------------------------------------------
Credential | MD
-----------------------------------------------------
Telephone | 305-934-1160
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207R00000X
-----------------------------------------------------
Taxonomy Name | Internal Medicine Physician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 207Q00000X
-----------------------------------------------------
Taxonomy Name | Family Medicine Physician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------