MEDICARE: INTEGRATED MEDICINE OF SOUTH FLORIDA

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	305R00000X	Preferred Provider Organization

General Provider Information

NPI Number	:	1235445305
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	INTEGRATED MEDICINE OF SOUTH FLORIDA

Provider Business Mailing Address
First Line	:	714 N W 62ND STREET
Second Line	:
City	:	MIAMI
State	:	FL
Zip	:	33150
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	714 NW 62ND ST
Second Line	:
City	:	MIAMI
State	:	FL
Zip	:	33150-4332
Country	:	US
Telephone Number	:	305-979-3770
Fax Number	:

Authorized Official
Title or Position	:	VICE PRESIDENT
Name	:	MR. THOMAS THELUSMA
Credential	:
Telephone Number	:	305-979-3770

Provider Enumeration Date	:	08/26/2010
Last Update Date	:	08/26/2010

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Directions to “INTEGRATED MEDICINE OF SOUTH FLORIDA ” Practice Location

Language	Start Address	Practice Location

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