Bluelakephysician Group

Primary specialty

Clinic/CenterTaxonomy code 261Q00000X

Legal business name

BLUELAKEPHYSICIAN GROUP

Practice address

4800 W Flagler St Ste 212
Coral Gables, FL 33134-1401

Phone

(786) 703-3195

Fax

(786) 703-3195

NPI assigned

Oct 18, 2021

Last updated

Oct 18, 2021By the provider in NPPES

Organization subpart

No

Registry information is reported by the provider to CMS and is not verified. About this source

Authorized official

Name

Dr. Trevine Roshan Albert I, OS14935

Title

Medical Director

Phone

(916) 225-6888

Specialties & licenses 2

Addresses

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1634515200000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1634515200000",
    "number": "1679236566",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "4800 W FLAGLER ST STE 212",
            "city": "CORAL GABLES",
            "state": "FL",
            "postal_code": "331341401",
            "telephone_number": "786-703-3195",
            "fax_number": "786-703-3195"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "4800 W FLAGLER ST STE 212",
            "city": "CORAL GABLES",
            "state": "FL",
            "postal_code": "331341401",
            "telephone_number": "786-703-3195",
            "fax_number": "786-703-3195"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "BLUELAKEPHYSICIAN GROUP",
        "organizational_subpart": "NO",
        "enumeration_date": "2021-10-18",
        "last_updated": "2021-10-18",
        "certification_date": "2021-10-18",
        "status": "A",
        "authorized_official_last_name": "ALBERT",
        "authorized_official_first_name": "TREVINE",
        "authorized_official_middle_name": "ROSHAN",
        "authorized_official_title_or_position": "MEDICAL DIRECTOR",
        "authorized_official_telephone_number": "916-225-6888",
        "authorized_official_name_prefix": "Dr.",
        "authorized_official_name_suffix": "I",
        "authorized_official_credential": "OS14935"
    },
    "taxonomies": [
        {
            "code": "261Q00000X",
            "taxonomy_group": "",
            "desc": "Clinic/Center",
            "state": "NU",
            "license": null,
            "primary": true
        },
        {
            "code": "2251S0007X",
            "taxonomy_group": "",
            "desc": "Physical Therapist, Sports",
            "state": "NU",
            "license": null,
            "primary": false
        }
    ],
    "identifiers": [],
    "endpoints": [],
    "other_names": []
}

• Blossom ABA Co.
• Blue Sky Med Inc
• Blue Star Medical Transport Inc
• Blue Wave Medical Services, Inc.
• Jacqueline L Blue, PH.D.
• Donna Glad Blythe, M.D.
• Stephen Earl Blythe, M.D.
• Calista Boaz
• Gustavo Adolfo Bobadilla, OTR/L
• Body and Mind Wellness Center, Inc

• Clinic/Center in Coral Gables, FL
• Providers in Coral Gables, FL by specialty
• Clinic/Center in Florida

• NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Oct 18, 2021; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
• National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.