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General NPI Number Information
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NPI Number | 1548716657
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Entity Type | Organization
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Legal Business Name | MEDSTATION MIAMI PRIMARY CARE LLC
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Dates
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Enumeration Date | 08/29/2016
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Last Update Date | 08/29/2016
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Provider Practice Location Address
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Address Line | 6701 SUNSET DR SUITE # 112
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City | SOUTH MIAMI
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State | FL
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Zip | 33143-4529
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Country | US
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Telephone | 305-667-1511
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Fax | 305-503-8955
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Provider Business Mailing Address
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Address Line | 6701 SUNSET DR SUITE # 112
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City | SOUTH MIAMI
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State | FL
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Zip | 33143-4529
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Country | US
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Telephone | 305-667-1511
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Fax | 305-503-8955
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Authorized Official
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Title or Position | MANAGEER MEMBER
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Name | THIERRY O. JACQUEMIN
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Credential | DO
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Telephone | 305-667-1511
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 207R00000X
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Taxonomy Name | Internal Medicine Physician
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License Number | OS9856
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License Number State | FL
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