Provider Demographics
NPI:1548716657
Name:MEDSTATION MIAMI PRIMARY CARE LLC
Entity type:Organization
Organization Name:MEDSTATION MIAMI PRIMARY CARE LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGEER MEMBER
Authorized Official - Prefix:
Authorized Official - First Name:THIERRY
Authorized Official - Middle Name:O
Authorized Official - Last Name:JACQUEMIN
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:305-667-1511
Mailing Address - Street 1:6701 SUNSET DR
Mailing Address - Street 2:SUITE # 112
Mailing Address - City:SOUTH MIAMI
Mailing Address - State:FL
Mailing Address - Zip Code:33143-4529
Mailing Address - Country:US
Mailing Address - Phone:305-667-1511
Mailing Address - Fax:305-503-8955
Practice Address - Street 1:6701 SUNSET DR
Practice Address - Street 2:SUITE # 112
Practice Address - City:SOUTH MIAMI
Practice Address - State:FL
Practice Address - Zip Code:33143-4529
Practice Address - Country:US
Practice Address - Phone:305-667-1511
Practice Address - Fax:305-503-8955
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-08-29
Last Update Date:2016-08-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLOS9856207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL001536700Medicaid
FL1750407086OtherNPI INDIVIDUAL
FLBS88STMedicare PIN