| Entity Name: | WEST 49TH STREET E.R. PHYSICIAN CORP. |
| Jurisdiction: | FLORIDA |
| Filing Type: | Domestic Profit |
| Status: | Inactive |
| Date Filed: | 28 Jun 1990 (35 years ago) |
| Document Number: | L84026 |
| FEI/EIN Number | 650207115 |
| Address: | 1501 SW 42 AVENUE, CORAL GABLES, FL, 33134 |
| Mail Address: | 1501 SW 42 AVENUE, P O BOX 14 1156, CORAL GABLES, FL, 33134 |
| ZIP code: | 33134 |
| County: | Miami-Dade |
| Place of Formation: | FLORIDA |
| NPI | Enumeration Date | Last Update Date | Mailing Address | Practice Location Address | |||||||||||||||||||||||||||||
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| 1922128826 | 2007-04-02 | 2012-10-29 | 1475 W 49TH ST, HIALEAH, FL, 330123222, US | 1475 W 49TH ST, HIALEAH, FL, 330123222, US | |||||||||||||||||||||||||||||
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| Phone | +1 305-558-2500 |
| Fax | 3058269002 |
Authorized person
| Name | MR. MARK EARLY |
| Role | CHIEF FINANCIAL OFFICER |
| Phone | 3058244703 |
Taxonomy
| Taxonomy Code | 207L00000X - Anesthesiology Physician |
| Is Primary | No |
| Taxonomy Code | 207PE0004X - Emergency Medical Services (Emergency Medicine) Physician |
| Is Primary | Yes |
| Taxonomy Code | 282N00000X - General Acute Care Hospital |
| Is Primary | No |
Other Provider Identifiers
| Issuer | MEDICAID |
| Number | 059554300 |
| State | FL |
| Name | Role | Address |
|---|---|---|
| FORMAN MAX | Agent | 1501 SW LEJEUNE ROAD, CORAL GABLES, FL, 33134 |
| Name | Role | Address |
|---|---|---|
| FORMAN MAX | President | 1501 SW LEJEUNE ROAD, CORAL GABLES, FL, 33134 |
| Event Type | Filed Date | Value | Description |
|---|---|---|---|
| ADMIN DISSOLUTION FOR ANNUAL REPORT | 2017-09-22 | No data | No data |
Date of last update: 02 Jan 2025
Sources: Florida Department of State
