1245539071 NPI number — DISSICK MEDICAL ASSOCIATES,PA

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 1245539071 NPI number — DISSICK MEDICAL ASSOCIATES,PA

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
DISSICK MEDICAL ASSOCIATES,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:
1245539071
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
04/05/2011
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
7301A PALMETTO PARK ROAD
Provider Second Line Business Mailing Address:
SUITE 301A
Provider Business Mailing Address City Name:
BOCA RATON
Provider Business Mailing Address State Name:
FL
Provider Business Mailing Address Postal Code:
33433
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
561-672-7950
Provider Business Mailing Address Fax Number:
561-672-7953

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
7301A PALMETTO PARK ROAD
Provider Second Line Business Practice Location Address:
SUITE 301A
Provider Business Practice Location Address City Name:
BOCA RATON
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
33433
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
561-672-7950
Provider Business Practice Location Address Fax Number:
561-672-7953
Provider Enumeration Date:
03/18/2011

Additional Information

Authorized Official

Authorized Official Last Name:
DISSICK
Authorized Official First Name:
ADDIE
Authorized Official Middle Name:
Authorized Official Title or Position:
OWNER
Authorized Official Telephone Number:
561-672-7950

Provider Taxonomy Codes

  • Taxonomy code: 207R00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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