Provider Demographics
NPI:1053138099
Name:BLUESHINE MEDICAL CENTER LLC
Entity type:Organization
Organization Name:BLUESHINE MEDICAL CENTER LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PROVIDER
Authorized Official - Prefix:DR
Authorized Official - First Name:JOSE
Authorized Official - Middle Name:GUSTAVO
Authorized Official - Last Name:CEVALLOS
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:305-790-6544
Mailing Address - Street 1:205 NW 15TH PL
Mailing Address - Street 2:
Mailing Address - City:CAPE CORAL
Mailing Address - State:FL
Mailing Address - Zip Code:33993-7747
Mailing Address - Country:US
Mailing Address - Phone:561-762-1660
Mailing Address - Fax:
Practice Address - Street 1:140 SANTA BARBARA BLVD STE 121
Practice Address - Street 2:
Practice Address - City:CAPE CORAL
Practice Address - State:FL
Practice Address - Zip Code:33991-2160
Practice Address - Country:US
Practice Address - Phone:305-790-6544
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2024-09-23
Last Update Date:2024-09-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral PracticeGroup - Single Specialty