Provider Demographics
NPI:1306094586
Name:MEDI MD
Entity type:Organization
Organization Name:MEDI MD
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:EXEC
Authorized Official - Prefix:
Authorized Official - First Name:SEBASTIAN
Authorized Official - Middle Name:
Authorized Official - Last Name:AHMED
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:888-674-0160
Mailing Address - Street 1:7950 SW 30TH ST STE 200
Mailing Address - Street 2:
Mailing Address - City:DAVIE
Mailing Address - State:FL
Mailing Address - Zip Code:33328-1979
Mailing Address - Country:US
Mailing Address - Phone:888-674-0160
Mailing Address - Fax:866-467-1802
Practice Address - Street 1:7950 SW 30TH ST STE 200
Practice Address - Street 2:
Practice Address - City:DAVIE
Practice Address - State:FL
Practice Address - Zip Code:33328-1979
Practice Address - Country:US
Practice Address - Phone:888-674-0160
Practice Address - Fax:888-467-1802
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-08-31
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL602238261QM1300X
FL0601261QR0405X
FL261QR0405X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261QR0405XAmbulatory Health Care FacilitiesClinic/CenterRehabilitation, Substance Use DisorderGroup - Multi-Specialty
No261QM1300XAmbulatory Health Care FacilitiesClinic/CenterMulti-SpecialtyGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLDQ5523OtherRR MEDICARE
FL001991000Medicaid
FL98322OtherBCBS
FL001991000Medicaid