Provider Demographics
NPI:1982420998
Name:ST JUDE MEDICAL GROUP CORP
Entity type:Organization
Organization Name:ST JUDE MEDICAL GROUP CORP
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEDICAL DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:MANUEL
Authorized Official - Middle Name:D
Authorized Official - Last Name:GONZALEZ
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:786-464-5120
Mailing Address - Street 1:2141 NW 7TH ST
Mailing Address - Street 2:
Mailing Address - City:MIAMI
Mailing Address - State:FL
Mailing Address - Zip Code:33125-3483
Mailing Address - Country:US
Mailing Address - Phone:786-464-5120
Mailing Address - Fax:786-464-5125
Practice Address - Street 1:11300 NW 87TH CT STE 141
Practice Address - Street 2:
Practice Address - City:HIALEAH GARDENS
Practice Address - State:FL
Practice Address - Zip Code:33018-4520
Practice Address - Country:US
Practice Address - Phone:786-464-5120
Practice Address - Fax:786-464-5125
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2024-11-25
Last Update Date:2024-11-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/Center