Basic Information
| Provider Information | |||||||||
| NPI: | 1124063540 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | PALM BEACH HEART ASSOCIATES PA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 5503 S CONGRESS AVE | ||||||||
| Address2: | SUITE 206 | ||||||||
| City: | ATLANTIS | ||||||||
| State: | FL | ||||||||
| PostalCode: | 334626625 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5614330591 | ||||||||
| FaxNumber: | 5614330891 | ||||||||
| Practice Location | |||||||||
| Address1: | 5503 S CONGRESS AVE | ||||||||
| Address2: | SUITE 206 | ||||||||
| City: | ATLANTIS | ||||||||
| State: | FL | ||||||||
| PostalCode: | 334626625 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5614330591 | ||||||||
| FaxNumber: | 5614330891 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/19/2006 | ||||||||
| LastUpdateDate: | 01/23/2015 | ||||||||
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| AuthorizedOfficialLastName: | MIDWALL | ||||||||
| AuthorizedOfficialFirstName: | JAY | ||||||||
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| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 5614330591 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | DR. | ||||||||
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| AuthorizedOfficialCredential: | MD | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207RC0000X | FL | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine | Cardiovascular Disease | 207RI0011X | FL | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine | Interventional Cardiology |
ID Information
| ID | Type | State | Issuer | Description | CL0618 | 01 | FL | MCR RR | OTHER | 97633 | 01 | FL | BCBS | OTHER | 254158100 | 05 | FL | MEDICAID |