MEDICARE: CENTRUM MEDICAL GROUP, PLLC

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	:	1922751288
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	CENTRUM MEDICAL GROUP, PLLC

Provider Business Mailing Address
First Line	:	9250 NW 36TH ST STE 420
Second Line	:
City	:	DORAL
State	:	FL
Zip	:	33178-2775
Country	:	US
Telephone Number	:	305-266-2929
Fax Number	:

Provider Business Practice Location Address
First Line	:	3410 PRESIDENT GEORGE BUSH TPKE
Second Line	:
City	:	DALLAS
State	:	TX
Zip	:	75287-6629
Country	:	US
Telephone Number	:	800-218-8989
Fax Number	:	786-558-0242

Authorized Official
Title or Position	:	COO
Name	:	VANESSA VICTORERO
Credential	:
Telephone Number	:	305-266-2929

Provider Enumeration Date	:	01/27/2022
Last Update Date	:	01/27/2022

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