Basic Information
| Provider Information | |||||||||
| NPI: | 1043241375 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | GERVASI | ||||||||
| FirstName: | MICHAEL | ||||||||
| MiddleName: | F | ||||||||
| NamePrefix: | DR. | ||||||||
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| Credential: | DO | ||||||||
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| Mailing Information | |||||||||
| Address1: | 4450 S TIFFANY DR | ||||||||
| Address2: | |||||||||
| City: | WEST PALM BEACH | ||||||||
| State: | FL | ||||||||
| PostalCode: | 334073241 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5618449443 | ||||||||
| FaxNumber: | 5618441013 | ||||||||
| Practice Location | |||||||||
| Address1: | 15858 SW WARFIELD BLVD | ||||||||
| Address2: | BOX 648 | ||||||||
| City: | INDIANTOWN | ||||||||
| State: | FL | ||||||||
| PostalCode: | 349560648 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7725973596 | ||||||||
| FaxNumber: | 7725974194 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/05/2006 | ||||||||
| LastUpdateDate: | 06/25/2012 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | OS5479 | FL | Y | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 371600700 | 05 | FL | MEDICAID |