1619415403 NPI number — JUPITER MEDICAL CENTER PHYSICIANS GROUP

Table of content: (NPI 1619415403)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1619415403 NPI number — JUPITER MEDICAL CENTER PHYSICIANS GROUP

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
JUPITER MEDICAL CENTER PHYSICIANS GROUP
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:
6
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:
1619415403
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
04/10/2023
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 9218
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
JUPITER
Provider Business Mailing Address State Name:
FL
Provider Business Mailing Address Postal Code:
33468-9218
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
561-263-2234
Provider Business Mailing Address Fax Number:
561-263-7260

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
625 N FLAGLER DR
Provider Second Line Business Practice Location Address:
SUITE 100
Provider Business Practice Location Address City Name:
WEST PALM BEACH
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
33401-4027
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
561-263-7010
Provider Business Practice Location Address Fax Number:
561-744-8215
Provider Enumeration Date:
02/01/2017

Additional Information

Authorized Official

Authorized Official Last Name:
MAGALHAES
Authorized Official First Name:
JUDY
Authorized Official Middle Name:
Authorized Official Title or Position:
VICE PRESIDENT
Authorized Official Telephone Number:
561-263-4354

Provider Taxonomy Codes

  • Taxonomy code: 261QU0200X , with the licence number:  HCC12419 , 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: 022692500 . This is a "Florida Medicaid Provider ID" identifier , issued by the state of ( FL ) . This identifiers is of the category "MEDICAID".




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