MEDICARE: ESMERALDA MEDICAL CENTER CORP

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	208D00000X	General Practice Physician

General Provider Information

NPI Number	:	1528593696
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	ESMERALDA MEDICAL CENTER CORP

Provider Business Mailing Address
First Line	:	14100 PALMETTO FRNTG RD
Second Line	:	SUITE 105
City	:	MIAMI LAKES
State	:	FL
Zip	:	33016-1569
Country	:	US
Telephone Number	:	786-443-3075
Fax Number	:

Provider Business Practice Location Address
First Line	:	14100 PALMETTO FRNTG RD
Second Line	:	SUITE 105
City	:	MIAMI LAKES
State	:	FL
Zip	:	33016-1569
Country	:	US
Telephone Number	:	305-342-3335
Fax Number	:

Authorized Official
Title or Position	:	OWNER
Name	:	IBELIS HERNANDEZ
Credential	:
Telephone Number	:	305-342-3335

Provider Enumeration Date	:	04/26/2017
Last Update Date	:	05/09/2017

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