MEDICARE: FAMILY &PEDIATRIC MEDICAL CENTER 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	207Q00000X	Family Medicine Physician

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1154991453
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	FAMILY &PEDIATRIC MEDICAL CENTER INC

Provider Business Mailing Address
First Line	:	3155 NW 82ND AVE STE 102
Second Line	:
City	:	DORAL
State	:	FL
Zip	:	33122-1056
Country	:	US
Telephone Number	:	305-348-1586
Fax Number	:	305-591-2995

Provider Business Practice Location Address
First Line	:	14850 SW 26TH ST STE 108
Second Line	:
City	:	MIAMI
State	:	FL
Zip	:	33185-5930
Country	:	US
Telephone Number	:	305-348-1586
Fax Number	:	305-591-2995

Authorized Official
Title or Position	:	PRESIDENT
Name	:	WILSON LOPEZ
Credential	:	MD
Telephone Number	:	305-591-2988

Provider Enumeration Date	:	06/29/2021
Last Update Date	:	06/29/2021

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