MEDICARE: PROMEDICAL CENTER HIALEAH 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	208100000X	Physical Medicine & Rehabilitation Physician	ME78770	FL

General Provider Information

NPI Number	:	1609388453
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	PROMEDICAL CENTER HIALEAH CORP

Provider Business Mailing Address
First Line	:	900 W 49TH ST STE 300
Second Line	:
City	:	HIALEAH
State	:	FL
Zip	:	33012-3407
Country	:	US
Telephone Number	:	786-953-4471
Fax Number	:	786-703-5185

Provider Business Practice Location Address
First Line	:	900 W 49TH ST STE 300
Second Line	:
City	:	HIALEAH
State	:	FL
Zip	:	33012-3407
Country	:	US
Telephone Number	:	786-953-4471
Fax Number	:	786-703-5185

Authorized Official
Title or Position	:	OWNER
Name	:	MR. RENE CASANOVA
Credential	:	MD
Telephone Number	:	786-953-4471

Provider Enumeration Date	:	11/02/2017
Last Update Date	:	11/02/2017

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