Provider Demographics
NPI:1306898242
Name:FERNANDEZ BLAY MD PA
Entity type:Organization
Organization Name:FERNANDEZ BLAY MD PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRES/OWNER
Authorized Official - Prefix:
Authorized Official - First Name:ROBERTO
Authorized Official - Middle Name:CARLOS
Authorized Official - Last Name:FERNANDEZ BLAY
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:305-322-8096
Mailing Address - Street 1:14143 SW 52ND ST
Mailing Address - Street 2:
Mailing Address - City:MIRAMAR
Mailing Address - State:FL
Mailing Address - Zip Code:33027-5978
Mailing Address - Country:US
Mailing Address - Phone:305-322-8096
Mailing Address - Fax:
Practice Address - Street 1:2488 N UNIVERSITY DR
Practice Address - Street 2:
Practice Address - City:PEMBROKE PINES
Practice Address - State:FL
Practice Address - Zip Code:33024-3624
Practice Address - Country:US
Practice Address - Phone:954-983-9191
Practice Address - Fax:305-829-1401
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-17
Last Update Date:2008-10-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME93447207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL274947500Medicaid
FLK9878Medicare PIN
FL274947500Medicaid