Basic Information
| Provider Information | |||||||||
| NPI: | 1134467129 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | OBGYN SPECIALISTS OF LAKESIDE LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2979 PGA BLVD | ||||||||
| Address2: | SUITE 200 | ||||||||
| City: | PALM BEACH GARDENS | ||||||||
| State: | FL | ||||||||
| PostalCode: | 334102911 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5612757604 | ||||||||
| FaxNumber: | 5618025385 | ||||||||
| Practice Location | |||||||||
| Address1: | 39200 HOOKER HWY | ||||||||
| Address2: | |||||||||
| City: | BELLE GLADE | ||||||||
| State: | FL | ||||||||
| PostalCode: | 334305368 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5619966571 | ||||||||
| FaxNumber: | 5619929722 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/25/2013 | ||||||||
| LastUpdateDate: | 07/06/2016 | ||||||||
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| AuthorizedOfficialLastName: | BURIGO | ||||||||
| AuthorizedOfficialFirstName: | JOHN | ||||||||
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| AuthorizedOfficialTitleorPosition: | MANAGER | ||||||||
| AuthorizedOfficialTelephone: | 5612757509 | ||||||||
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| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | OBGYN SPECIALISTS OF THE PALM BEACHES PA | ||||||||
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| AuthorizedOfficialCredential: | MD | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207VM0101X | ME35335 | FL | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Obstetrics & Gynecology | Maternal & Fetal Medicine | 207V00000X | ME35335 | FL | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Obstetrics & Gynecology |
ID Information
| ID | Type | State | Issuer | Description | 008257000 | 05 | FL | MEDICAID |