MEDICARE: AXIS LE PROFESSIONAL MEDICAL GROUP

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	302R00000X	Health Maintenance Organization

General Provider Information

NPI Number	:	1245587302
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	AXIS LE PROFESSIONAL MEDICAL GROUP

Provider Business Mailing Address
First Line	:	2604 NW 21ST TER
Second Line	:
City	:	MIAMI
State	:	FL
Zip	:	33142-7113
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	2604 NW 21ST TER
Second Line	:
City	:	MIAMI
State	:	FL
Zip	:	33142-7113
Country	:	US
Telephone Number	:	305-877-8184
Fax Number	:

Authorized Official
Title or Position	:	PRESIDENT
Name	:	ERENDIRA DELGADO
Credential	:
Telephone Number	:	305-877-8184

Provider Enumeration Date	:	08/08/2012
Last Update Date	:	08/08/2012

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Directions to “AXIS LE PROFESSIONAL MEDICAL GROUP ” Practice Location

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