=====================================================
General NPI Number Information
=====================================================
NPI Number | 1083874275
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | IFA MEDICAL CENTER INC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/11/2008
-----------------------------------------------------
Last Update Date | 07/22/2008
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1695 SW 107TH AVE SUITE 201
-----------------------------------------------------
City | MIAMI
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33165-7344
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 305-207-4443
-----------------------------------------------------
Fax | 305-207-4442
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1695 SW 107TH AVE SUITE 201
-----------------------------------------------------
City | MIAMI
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33165-7344
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 305-207-4443
-----------------------------------------------------
Fax | 305-207-4442
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT
-----------------------------------------------------
Name | ELIEZER GONZALEZ
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 305-207-4443
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QR0200X
-----------------------------------------------------
Taxonomy Name | Radiology Clinic/Center
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------