Provider Demographics
NPI:1063417483
Name:PUBLIC HEALTH TRUST OF MIAMI DADE COUNTY FLORIDA
Entity type:Organization
Organization Name:PUBLIC HEALTH TRUST OF MIAMI DADE COUNTY FLORIDA
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CHIEF FINANCIAL OFFICER
Authorized Official - Prefix:MR
Authorized Official - First Name:MARK
Authorized Official - Middle Name:T
Authorized Official - Last Name:KNIGHT
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:305-585-7979
Mailing Address - Street 1:P.O. BOX 12493
Mailing Address - Street 2:
Mailing Address - City:MIAMI
Mailing Address - State:FL
Mailing Address - Zip Code:33101-2493
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:15055 NW 27 AVENUE
Practice Address - Street 2:
Practice Address - City:OPA-LOCKA
Practice Address - State:FL
Practice Address - Zip Code:33054-3365
Practice Address - Country:US
Practice Address - Phone:305-466-2800
Practice Address - Fax:786-466-2748
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-06-14
Last Update Date:2020-09-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL8511261QC1500X, 261QM0850X, 261QM0855X, 261QM0801X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM0801XAmbulatory Health Care FacilitiesClinic/CenterMental Health (Including Community Mental Health Center)
No261QC1500XAmbulatory Health Care FacilitiesClinic/CenterCommunity Health
No261QM0850XAmbulatory Health Care FacilitiesClinic/CenterAdult Mental Health
No261QM0855XAmbulatory Health Care FacilitiesClinic/CenterAdolescent and Children Mental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL014357500Medicaid
FL075501000Medicaid
FL142202200OtherASSISTED CARE SERVICES
FL005851600Medicaid
FL912237100Medicaid
FL912301600Medicaid
FL686226896Medicaid