1265614754 NPI number — PRIMARY CARE SPECIALISTS OF THE PALM BEACHES LLC

Table of content: (NPI 1265614754)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1265614754 NPI number — PRIMARY CARE SPECIALISTS OF THE PALM BEACHES LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
PRIMARY CARE SPECIALISTS OF THE PALM BEACHES LLC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
CONVIVA CARE CENTER
Provider Other Organization Name Type Code:
3
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1265614754
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
02/03/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
6101 BLUE LAGOON DR STE 400
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
MIAMI
Provider Business Mailing Address State Name:
FL
Provider Business Mailing Address Postal Code:
33126-2051
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
305-500-2000
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
6101 BLUE LAGOON DR STE 400
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
MIAMI
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
33126-2051
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
305-662-5200
Provider Business Practice Location Address Fax Number:
305-284-7948
Provider Enumeration Date:
11/27/2007

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
ROSELLO
Authorized Official First Name:
GEMMA
Authorized Official Middle Name:
Authorized Official Title or Position:
VP
Authorized Official Telephone Number:
305-500-2000

Provider Taxonomy Codes

  • Taxonomy code: 207R00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 012616300 , issued by the state of ( FL ) . This identifiers is of the category "MEDICAID".
  • Identifier: 012616302 , issued by the state of ( FL ) . This identifiers is of the category "MEDICAID".
  • Identifier: 012616303 , issued by the state of ( FL ) . This identifiers is of the category "MEDICAID".
  • Identifier: 012616301 , issued by the state of ( FL ) . This identifiers is of the category "MEDICAID".