1154317204 NPI number — MEDERI OF PALM BEACH COUNTY, 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 1154317204 NPI number — MEDERI OF PALM BEACH COUNTY, INC.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
MEDERI OF PALM BEACH COUNTY, 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:
1154317204
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/22/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
9510 ORMSBY STATION RD
Provider Second Line Business Mailing Address:
STE 300
Provider Business Mailing Address City Name:
LOUISVILLE
Provider Business Mailing Address State Name:
KY
Provider Business Mailing Address Postal Code:
40223-4081
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
502-891-1000
Provider Business Mailing Address Fax Number:
502-891-8067

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
4723 W ATLANTIC AVE
Provider Second Line Business Practice Location Address:
STE A14
Provider Business Practice Location Address City Name:
DELRAY BEACH
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
33445-3895
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
561-381-1077
Provider Business Practice Location Address Fax Number:
561-496-0357
Provider Enumeration Date:
09/23/2005

Additional Information

Authorized Official

Authorized Official Last Name:
GUENTHNER
Authorized Official First Name:
C.
Authorized Official Middle Name:
STEVEN
Authorized Official Title or Position:
SR VP, CFO
Authorized Official Telephone Number:
502-891-1000

Provider Taxonomy Codes

  • Taxonomy code: 251E00000X , with the licence number:  20693096 , 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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