Provider Demographics
NPI:1104126952
Name:THE MEDICAL GROUP OF SOUTH FLORIDA INC
Entity type:Organization
Organization Name:THE MEDICAL GROUP OF SOUTH FLORIDA INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:JOSHUA
Authorized Official - Middle Name:
Authorized Official - Last Name:SMITH
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:561-622-6111
Mailing Address - Street 1:1094 MILITARY TRL DEPT 4101
Mailing Address - Street 2:
Mailing Address - City:JUPITER
Mailing Address - State:FL
Mailing Address - Zip Code:33458-7021
Mailing Address - Country:US
Mailing Address - Phone:561-622-6111
Mailing Address - Fax:561-246-3721
Practice Address - Street 1:1094 MILITARY TRL
Practice Address - Street 2:
Practice Address - City:JUPITER
Practice Address - State:FL
Practice Address - Zip Code:33458-7021
Practice Address - Country:US
Practice Address - Phone:561-622-6111
Practice Address - Fax:561-622-1176
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-10-27
Last Update Date:2018-09-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
174400000X
FLME98294207X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic SurgeryGroup - Multi-Specialty
Yes174400000XOther Service ProvidersSpecialistGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL000S2OtherBLUE SHIELD OF FLORIDA
FL99567OtherBCBS
FL002251800Medicaid