Provider Demographics
NPI:1285748285
Name:SOUTH DADE PRIMARY CARE, LLC
Entity type:Organization
Organization Name:SOUTH DADE PRIMARY CARE, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CHIEF EXECUTIVE OFFICER
Authorized Official - Prefix:
Authorized Official - First Name:MARK
Authorized Official - Middle Name:L
Authorized Official - Last Name:MULLINIX
Authorized Official - Suffix:
Authorized Official - Credentials:AUTHORIZED OFFICIAL
Authorized Official - Phone:786-758-3135
Mailing Address - Street 1:1000 NW 57TH CT STE 400
Mailing Address - Street 2:
Mailing Address - City:MIAMI
Mailing Address - State:FL
Mailing Address - Zip Code:33126-3292
Mailing Address - Country:US
Mailing Address - Phone:786-485-1005
Mailing Address - Fax:786-441-2156
Practice Address - Street 1:9835 E HIBISCUS ST
Practice Address - Street 2:
Practice Address - City:PALMETTO BAY
Practice Address - State:FL
Practice Address - Zip Code:33157-5406
Practice Address - Country:US
Practice Address - Phone:305-238-8561
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:CLAREMEDICA HEALTH PARTNERS, LLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2006-08-18
Last Update Date:2025-08-27
Deactivation Date:2023-04-26
Deactivation Code:
Reactivation Date:2023-05-10
Provider Licenses
StateLicense IDTaxonomies
FLME0027176207Q00000X
FLME0092409207Q00000X
FLME0016658207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
01-02953OtherUNITED HEALTHCARE
01-02956OtherUNITED HEALTHCARE
4347956OtherAETNA INSURANCE
71520OtherBLUE CROSS BLUE SHIELD FL
79328OtherBLEU CROSS BLUE SHIELD FL
005597OtherNEIGHBORHOOD HEALTH PARTN
4497709OtherAETNA INSURANCE
15296OtherAETNA INSURANCE
15313OtherAETNA INSURANCE
4497709OtherAETNA INSURANCE
4497709OtherAETNA INSURANCE
79328OtherBLEU CROSS BLUE SHIELD FL
71520OtherBLUE CROSS BLUE SHIELD FL
D58100Medicare UPIN