1780814103 NPI number — PALM BEACH DERMATOLOGY INSTITUTE, INC.

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1780814103 NPI number — PALM BEACH DERMATOLOGY INSTITUTE, INC.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
PALM BEACH DERMATOLOGY INSTITUTE, INC.
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:
1780814103
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/25/2009
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1760 N CONGRESS AVE
Provider Second Line Business Mailing Address:
SUITE 200
Provider Business Mailing Address City Name:
BOYNTON BEACH
Provider Business Mailing Address State Name:
FL
Provider Business Mailing Address Postal Code:
33426-8214
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
561-733-0077
Provider Business Mailing Address Fax Number:
561-733-0020

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1760 N CONGRESS AVE
Provider Second Line Business Practice Location Address:
SUITE 200
Provider Business Practice Location Address City Name:
BOYNTON BEACH
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
33426-8214
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
561-733-0077
Provider Business Practice Location Address Fax Number:
561-733-0020
Provider Enumeration Date:
07/20/2009

Additional Information

Authorized Official

Authorized Official Last Name:
RIDGWAY
Authorized Official First Name:
HAL
Authorized Official Middle Name:
BLAKE
Authorized Official Title or Position:
PRES
Authorized Official Telephone Number:
561-964-7500

Provider Taxonomy Codes

  • Taxonomy code: 261QM2500X , with the licence number:  ME54995 , 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)





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