1104453190 NPI number — MICHAEL VINCENT MAMONE

Table of content: MICHAEL VINCENT MAMONE (NPI 1104453190)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1104453190 NPI number — MICHAEL VINCENT MAMONE

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
MAMONE
Provider First Name:
MICHAEL
Provider Middle Name:
VINCENT
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:
M

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:
1104453190
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/07/2023
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
FLORIDA ATLANTIC UNIVERSITY MEDICINE AT BOCA RATON
Provider Second Line Business Mailing Address:
1001 NW 13TH STREET, STE. 201
Provider Business Mailing Address City Name:
BOCA RATON
Provider Business Mailing Address State Name:
FL
Provider Business Mailing Address Postal Code:
33486
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
561-955-6663
Provider Business Mailing Address Fax Number:
561-955-2879

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2815 S SEACREST BLVD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
BOYNTON BEACH
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
33435-7969
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
561-292-4949
Provider Business Practice Location Address Fax Number:
833-625-1623
Provider Enumeration Date:
03/27/2020

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 207R00000X , with the licence number:  ME163454 , 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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