MEDICARE: SOUTHGATE MEDICAL OF FLORIDA, INC.

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	332BP3500X	Parenteral & Enteral Nutrition Supplies (DME)	976	FL

General Provider Information

NPI Number	:	1154477214
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	SOUTHGATE MEDICAL OF FLORIDA, INC.

Provider Business Mailing Address
First Line	:	899 NW 4TH ST
Second Line	:
City	:	MIAMI
State	:	FL
Zip	:	33128-1309
Country	:	US
Telephone Number	:	305-926-0960
Fax Number	:	305-326-1647

Provider Business Practice Location Address
First Line	:	899 NW 4TH ST
Second Line	:
City	:	MIAMI
State	:	FL
Zip	:	33128-1309
Country	:	US
Telephone Number	:	305-926-0960
Fax Number	:	305-326-1647

Authorized Official
Title or Position	:	VICE-PRESIDENT
Name	:	MR. RICHARD EUGENE STACEY SR.
Credential	:	LNHA
Telephone Number	:	305-926-0960

Provider Enumeration Date	:	01/25/2007
Last Update Date	:	08/22/2020

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