Provider Demographics
NPI:1942505243
Name:MIBASO
Entity type:Organization
Organization Name:MIBASO
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:DR
Authorized Official - First Name:AHUVA
Authorized Official - Middle Name:
Authorized Official - Last Name:GAMLIEL
Authorized Official - Suffix:
Authorized Official - Credentials:AP
Authorized Official - Phone:786-537-0771
Mailing Address - Street 1:1045 KANE CONCOURSE
Mailing Address - Street 2:214
Mailing Address - City:BAY HARBOR ISLANDS
Mailing Address - State:FL
Mailing Address - Zip Code:33154-2119
Mailing Address - Country:US
Mailing Address - Phone:786-537-0771
Mailing Address - Fax:
Practice Address - Street 1:1045 KANE CONCOURSE
Practice Address - Street 2:214
Practice Address - City:BAY HARBOR ISLANDS
Practice Address - State:FL
Practice Address - Zip Code:33154-2119
Practice Address - Country:US
Practice Address - Phone:786-537-0771
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-01-18
Last Update Date:2011-01-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLAP2313302R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes302R00000XManaged Care OrganizationsHealth Maintenance Organization