Provider Demographics
NPI:1871698027
Name:FRAGA MEDICAL CENTER, INC.
Entity type:Organization
Organization Name:FRAGA MEDICAL CENTER, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEDICAL DIRECTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:RENE
Authorized Official - Middle Name:
Authorized Official - Last Name:CASANOVA
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:954-816-7795
Mailing Address - Street 1:4141 SW 6TH ST
Mailing Address - Street 2:
Mailing Address - City:CORAL GABLES
Mailing Address - State:FL
Mailing Address - Zip Code:33134-2057
Mailing Address - Country:US
Mailing Address - Phone:305-443-5031
Mailing Address - Fax:
Practice Address - Street 1:11865 CORAL WAY
Practice Address - Street 2:SUITE B-7
Practice Address - City:MIAMI
Practice Address - State:FL
Practice Address - Zip Code:33175-2400
Practice Address - Country:US
Practice Address - Phone:305-220-6128
Practice Address - Fax:305-227-2855
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-13
Last Update Date:2018-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLACN961207Q00000X
2080A0000X, 208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral PracticeGroup - Multi-Specialty
No207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
No2080A0000XAllopathic & Osteopathic PhysiciansPediatricsAdolescent MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL279234600Medicaid
FL054135400Medicaid