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 1:14750 NW 77TH CT STE 100
Mailing Address - Street 2:
Mailing Address - City:MIAMI LAKES
Mailing Address - State:FL
Mailing Address - Zip Code:33016-1507
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:2025-02-27
Deactivation Date:2023-04-26
Deactivation Code:
Reactivation Date:2023-05-10
Provider Licenses
StateLicense IDTaxonomies
FLME0016658207Q00000X
FLME0027176207Q00000X
FLME0092409207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
4347956OtherAETNA INSURANCE
4497709OtherAETNA INSURANCE
005597OtherNEIGHBORHOOD HEALTH PARTN
71520OtherBLUE CROSS BLUE SHIELD FL
79328OtherBLEU CROSS BLUE SHIELD FL
15296OtherAETNA INSURANCE
01-02953OtherUNITED HEALTHCARE
01-02956OtherUNITED HEALTHCARE
15313OtherAETNA INSURANCE
4497709OtherAETNA INSURANCE
4497709OtherAETNA INSURANCE
79328OtherBLEU CROSS BLUE SHIELD FL
71520OtherBLUE CROSS BLUE SHIELD FL
D58100Medicare UPIN