1598739831 NPI number — PALM BEACH PEDIATRIC UROLOGY

Table of content: (NPI 1598739831)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1598739831 NPI number — PALM BEACH PEDIATRIC UROLOGY

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
PALM BEACH PEDIATRIC UROLOGY
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:
1598739831
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
10/22/2013
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
10301 HAGEN RANCH RD
Provider Second Line Business Mailing Address:
SUITE C130
Provider Business Mailing Address City Name:
BOYNTON BEACH
Provider Business Mailing Address State Name:
FL
Provider Business Mailing Address Postal Code:
33437
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
561-736-7313
Provider Business Mailing Address Fax Number:
561-736-2309

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
10301 HAGEN RANCH RD
Provider Second Line Business Practice Location Address:
SUITE C130
Provider Business Practice Location Address City Name:
BOYNTON BEACH
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
33437
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
561-736-7313
Provider Business Practice Location Address Fax Number:
561-736-2309
Provider Enumeration Date:
02/14/2006

Additional Information

Authorized Official

Authorized Official Last Name:
FLACK
Authorized Official First Name:
CHARLES
Authorized Official Middle Name:
E
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
561-512-0614

Provider Taxonomy Codes

  • Taxonomy code: 208800000X , with the licence number:  ME599337 , registered in the state of FL ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 2032607 . This is a "AETNA HMO" identifier , issued by the state of ( FL ) . This identifiers is of the category "OTHER".
  • Identifier: 272189900 , issued by the state of ( FL ) . This identifiers is of the category "MEDICAID".
  • Identifier: 4611456 . This is a "AETNA NON-HMO" identifier , issued by the state of ( FL ) . This identifiers is of the category "OTHER".
  • Identifier: 1755943 . This is a "CIGNA" identifier , issued by the state of ( FL ) . This identifiers is of the category "OTHER".
  • Identifier: 5962 . This is a "NHP" identifier , issued by the state of ( FL ) . This identifiers is of the category "OTHER".
  • Identifier: 103690 . This is a "AVMED" identifier , issued by the state of ( FL ) . This identifiers is of the category "OTHER".
  • Identifier: 204200 . This is a "AMERIGROUP" identifier , issued by the state of ( FL ) . This identifiers is of the category "OTHER".
  • Identifier: 12475 . This is a "BCBS" identifier , issued by the state of ( FL ) . This identifiers is of the category "OTHER".
  • Identifier: 26943 . This is a "WELLCARE" identifier , issued by the state of ( FL ) . This identifiers is of the category "OTHER".




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