| Entity Name: | MIAMI LAKES MEDICAL CENTER ASSOCIATES, P.A. |
| Jurisdiction: | FLORIDA |
| Filing Type: | Domestic Profit |
| Status: | Active |
| Date Filed: | 19 Dec 1991 (33 years ago) |
| Document Number: | V01580 |
| FEI/EIN Number | 650301430 |
| Address: | 2300 W 84th Avenue, #502, HIALEAH, FL, 33016, US |
| Mail Address: | 2300 W 84th Avenue, #502, HIALEAH, FL, 33016, US |
| ZIP code: | 33016 |
| County: | Miami-Dade |
| Place of Formation: | FLORIDA |
| NPI | Enumeration Date | Last Update Date | Mailing Address | Practice Location Address | |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| 1679758817 | 2008-01-07 | 2010-03-10 | 7150 W 20TH AVE, SUITE 315, HIALEAH, FL, 330165529, US | 7150 W 20TH AVE, SUITE 315, HIALEAH, FL, 330165529, US | |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
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| Phone | +1 305-821-6600 |
| Fax | 3058210773 |
Authorized person
| Name | BRIAN A ZALIS |
| Role | PRESIDENT |
| Phone | 3058216600 |
Taxonomy
| Taxonomy Code | 207Q00000X - Family Medicine Physician |
| License Number | ME31692 |
| State | FL |
| Is Primary | Yes |
Other Provider Identifiers
| Issuer | NHP KOBY |
| Number | 000901 |
| State | FL |
| Issuer | MEDICAID |
| Number | 039823300 |
| State | FL |
| Issuer | HUMANA |
| Number | 170130 |
| State | FL |
| Issuer | MCR KOBY |
| Number | 02704 |
| State | FL |
| Issuer | AETNA KOBY |
| Number | 4337911 |
| State | FL |
| Issuer | NHP ZALIS |
| Number | 001729 |
| State | FL |
| Issuer | AETNA ZALIS |
| Number | 4521008 |
| State | FL |
| Issuer | JMH ZALIS |
| Number | 6972300 |
| State | FL |
| Issuer | JMH KOBY |
| Number | 7900000 |
| State | FL |
| Issuer | MCR ZALIS |
| Number | 79162 |
| State | FL |
| Issuer | AVMED KOBY |
| Number | 014686 |
| State | FL |
| Issuer | BCBS KOBY |
| Number | 02704 |
| State | FL |
| Issuer | MEDICAID |
| Number | 044892300 |
| State | FL |
| Issuer | AVMED ZALIS |
| Number | 265997 |
| State | FL |
| Issuer | BCBS ZALIS |
| Number | 79162 |
| State | FL |
| Name | Role | Address |
|---|---|---|
| SNYDER SHAWN C | Agent | 7931 SW 45TH STREET, DAVIE, FL, 33328 |
| Name | Role | Address |
|---|---|---|
| ZALIS BRIAN ADr. | Director | 2300 W 84th Avenue, HIALEAH, FL, 33016 |
| KOBY RICHARD ADr. | Director | 2300 W 84th Avenue, HIALEAH, FL, 33016 |
| Name | Role | Address |
|---|---|---|
| ZALIS BRIAN ADr. | President | 2300 W 84th Avenue, HIALEAH, FL, 33016 |
| Name | Role | Address |
|---|---|---|
| KOBY RICHARD ADr. | Vice President | 2300 W 84th Avenue, HIALEAH, FL, 33016 |
| Registration Number | Fictitious Name | Status | Filed Date | Expiration Date | Cancellation Date | Mailing Address |
|---|---|---|---|---|---|---|
| G10000093822 | PEMBROKE LAKES MEDICAL CENTER | ACTIVE | 2010-10-13 | 2025-12-31 | No data | 650 NW 180TH TERRACE, SUITE 102, PEMBROKE PINES, FL, 33029 |
Date of last update: 01 Jan 2025
Sources: Florida Department of State
