=====================================================
General NPI Number Information
=====================================================
NPI Number | 1417237322
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | POWER MEDICAL CENTER, INC.
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/23/2011
-----------------------------------------------------
Last Update Date | 08/23/2011
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 107 N KROME AVE
-----------------------------------------------------
City | HOMESTEAD
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33030-6016
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 305-247-7765
-----------------------------------------------------
Fax | 305-247-7796
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 107 N KROME AVE
-----------------------------------------------------
City | HOMESTEAD
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33030-6016
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 305-247-7765
-----------------------------------------------------
Fax | 305-247-7796
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | CREDENTIALING
-----------------------------------------------------
Name | EVELIN GAMEZ
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 786-512-0464
-----------------------------------------------------
=====================================================
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 |
-----------------------------------------------------