MEDICARE: MIDLAND MEDICAL MIAMI SHORES INC

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	207Q00000X	Family Medicine Physician	OS9305	FL

General Provider Information

NPI Number	:	1639215551
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	MIDLAND MEDICAL MIAMI SHORES INC

Provider Business Mailing Address
First Line	:	8642 NE 2ND AVE
Second Line	:
City	:	MIAMI SHORES
State	:	FL
Zip	:	33138-3004
Country	:	US
Telephone Number	:	305-751-9677
Fax Number	:	305-751-9808

Provider Business Practice Location Address
First Line	:	8642 NE 2ND AVE
Second Line	:
City	:	MIAMI SHORES
State	:	FL
Zip	:	33138-3004
Country	:	US
Telephone Number	:	305-751-9677
Fax Number	:	305-751-9808

Authorized Official
Title or Position	:	DIRECTOR
Name	:	NOAH J LEE
Credential	:	DO
Telephone Number	:	305-751-9677

Provider Enumeration Date	:	01/29/2007
Last Update Date	:	10/31/2007

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