MEDICARE: IDALIA M SANTAELLA MD LLC

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	291U00000X	Clinical Medical Laboratory	ME 0044084	FL

General Provider Information

NPI Number	:	1376887117
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	IDALIA M SANTAELLA MD LLC

Provider Business Mailing Address
First Line	:	PO BOX 140878
Second Line	:
City	:	CORAL GABLES
State	:	FL
Zip	:	33114-0878
Country	:	US
Telephone Number	:	305-448-7213
Fax Number	:	305-448-9282

Provider Business Practice Location Address
First Line	:	2307 DOUGLAS RD
Second Line	:	SUITE 203
City	:	MIAMI
State	:	FL
Zip	:	33145-3056
Country	:	US
Telephone Number	:	305-448-7213
Fax Number	:	305-448-9282

Authorized Official
Title or Position	:	MEDICAL DIRECTOR
Name	:	DR. IDALIA M SANTAELLA
Credential	:	M.D.
Telephone Number	:	305-448-7213

Provider Enumeration Date	:	11/17/2012
Last Update Date	:	01/23/2013

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