Provider Demographics
NPI:1356351605
Name:BERAJA MEDICAL INSTITUTE INC
Entity type:Organization
Organization Name:BERAJA MEDICAL INSTITUTE INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:THOMAS
Authorized Official - Middle Name:ALBERT
Authorized Official - Last Name:QUIGLEY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:239-466-2020
Mailing Address - Street 1:44 BARKLEY CIR
Mailing Address - Street 2:
Mailing Address - City:FORT MYERS
Mailing Address - State:FL
Mailing Address - Zip Code:33907-7530
Mailing Address - Country:US
Mailing Address - Phone:239-985-7171
Mailing Address - Fax:392-985-7118
Practice Address - Street 1:2550 S DOUGLAS RD
Practice Address - Street 2:
Practice Address - City:CORAL GABLES
Practice Address - State:FL
Practice Address - Zip Code:33134-6126
Practice Address - Country:US
Practice Address - Phone:305-443-7070
Practice Address - Fax:305-357-1701
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-09
Last Update Date:2024-04-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL208200000X, 207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmologyGroup - Multi-Specialty
No208200000XAllopathic & Osteopathic PhysiciansPlastic SurgeryGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL33058OtherPTAN
FL377570400Medicaid
FL0913720001Medicare NSC
FL377570400Medicaid