=====================================================
General NPI Number Information
=====================================================
NPI Number | 1104101666
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | MIAMI COMPREHENSIVE MEDICINE GROUP PA
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/17/2011
-----------------------------------------------------
Last Update Date | 05/29/2024
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 4685 PONCE DE LEON BLVD
-----------------------------------------------------
City | CORAL GABLES
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33146-2108
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 305-851-2870
-----------------------------------------------------
Fax | 305-851-2871
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 345 PALERMO AVE
-----------------------------------------------------
City | CORAL GABLES
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33134-6607
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 305-851-2870
-----------------------------------------------------
Fax | 305-851-2871
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT
-----------------------------------------------------
Name | HEATHER L MASON
-----------------------------------------------------
Credential | MD
-----------------------------------------------------
Telephone | 305-851-2870
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207R00000X
-----------------------------------------------------
Taxonomy Name | Internal Medicine Physician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------