MEDICARE: CENTRO MIDWAY AMNISTIA Y MEDICO

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	ME50431	FL

General Provider Information

NPI Number	:	1053581587
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	CENTRO MIDWAY AMNISTIA Y MEDICO

Provider Business Mailing Address
First Line	:	85 GRAND CANAL DR STE 107
Second Line	:
City	:	MIAMI
State	:	FL
Zip	:	33144-2566
Country	:	US
Telephone Number	:	305-267-0744
Fax Number	:	305-267-0755

Provider Business Practice Location Address
First Line	:	85 GRAND CANAL DR STE 107
Second Line	:
City	:	MIAMI
State	:	FL
Zip	:	33144-2566
Country	:	US
Telephone Number	:	305-267-0744
Fax Number	:	305-267-0755

Authorized Official
Title or Position	:	FAMILY PHYSICIAN
Name	:	JOHN G PADRON
Credential	:	MD
Telephone Number	:	305-267-0744

Provider Enumeration Date	:	03/12/2008
Last Update Date	:	03/12/2008

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