1760456172 NPI number — MARK AND KAMBOUR MD PA

Table of content: (NPI 1760456172)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1760456172 NPI number — MARK AND KAMBOUR MD PA

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
MARK AND KAMBOUR MD PA
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:
Provider Other Organization Name Type Code:
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:
1760456172
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
03/11/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
11025 RCA CENTER DR STE 300
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
PALM BEACH GARDENS
Provider Business Mailing Address State Name:
FL
Provider Business Mailing Address Postal Code:
33410-4269
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
561-514-5822
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
16250 NW 59TH AVE STE 201
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
MIAMI LAKES
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
33014-7542
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
305-825-4422
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
02/14/2006

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
GRATTENDICK
Authorized Official First Name:
MICHAEL
Authorized Official Middle Name:
Authorized Official Title or Position:
CFO
Authorized Official Telephone Number:
561-514-5822

Provider Taxonomy Codes

  • Taxonomy code: 207ZC0500X , with the licence number:  ME35872 , registered in the state of FL ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 207ZP0102X , with the licence number: ME35872 , registered in the state of FL ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 207ZP0105X , with the licence number: ME35872 , registered in the state of FL ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

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