=====================================================
General NPI Number Information
=====================================================
NPI Number | 1861050700
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | OLIVER BAIN ACOSTA MD
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/05/2019
-----------------------------------------------------
Last Update Date | 08/15/2024
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1475 NW 12TH AVE
-----------------------------------------------------
City | MIAMI
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33136-1002
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 305-243-6605
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 110 N FEDERAL HWY APT 508
-----------------------------------------------------
City | FORT LAUDERDALE
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33301-1182
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 305-992-9674
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 2081P0301X
-----------------------------------------------------
Taxonomy Name | Brain Injury Medicine (Physical Medicine & Rehabilitation) Physician
-----------------------------------------------------
License Number | ME168097
-----------------------------------------------------
License Number State | FL
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 208100000X
-----------------------------------------------------
Taxonomy Name | Physical Medicine & Rehabilitation Physician
-----------------------------------------------------
License Number | ME168097
-----------------------------------------------------
License Number State | FL
-----------------------------------------------------