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General NPI Number Information
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NPI Number | 1831468669
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Entity Type | Organization
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Legal Business Name | INTERACTIVE MEDICAL - UNLIMITED SURGICAL ASSISTANT
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Dates
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Enumeration Date | 12/23/2011
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Last Update Date | 12/23/2011
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Provider Practice Location Address
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Address Line | 49 N FEDERAL HWY # 361
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City | POMPANO BEACH
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State | FL
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Zip | 33062-4304
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Country | US
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Telephone | 954-990-3515
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Fax |
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Provider Business Mailing Address
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Address Line | 49 N FEDERAL HWY # 361
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City | POMPANO BEACH
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State | FL
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Zip | 33062-4304
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Country | US
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Telephone | 954-990-3515
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Fax |
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Authorized Official
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Title or Position | PRESIDENT
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Name | MR. MIGUEL ANGEL ORTIZ DIAZ
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Credential | PA-C
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Telephone | 954-990-3515
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 363AS0400X
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Taxonomy Name | Surgical Physician Assistant
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License Number | PA9101223
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License Number State | FL
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