MEDICARE: PMC JACKSON SOUTH, LLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	261Q00000X	Clinic/Center		FL

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	207R00000X	OTHER	FL	TAXONOMY

General Provider Information

NPI Number	:	1043469232
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	PMC JACKSON SOUTH, LLC

Provider Business Mailing Address
First Line	:	12550 BISCAYNE BLVD STE 500
Second Line	:
City	:	NORTH MIAMI
State	:	FL
Zip	:	33181-2544
Country	:	US
Telephone Number	:	305-868-7180
Fax Number	:

Provider Business Practice Location Address
First Line	:	9380 SW 150TH ST STE 100
Second Line	:
City	:	MIAMI
State	:	FL
Zip	:	33176-7979
Country	:	US
Telephone Number	:	305-253-2665
Fax Number	:

Authorized Official
Title or Position	:	MNG MBR
Name	:	MR. SPENCER ANGEL
Credential	:
Telephone Number	:	305-868-7180

Provider Enumeration Date	:	09/12/2008
Last Update Date	:	09/12/2008

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