Basic Information
| Provider Information | |||||||||
| NPI: | 1407022601 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | HEALTH CARE DISTRICT OF PALM BEACH COUNTY | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
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| Credential: | |||||||||
| OtherOrganizationName: | LAKESIDE PHYSICIAN PRACTICE | ||||||||
| OtherOrganizationType: | 3 | ||||||||
| OtherLastName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | 1515 N FLAGLER DR STE 101 | ||||||||
| Address2: | |||||||||
| City: | WEST PALM BEACH | ||||||||
| State: | FL | ||||||||
| PostalCode: | 334013429 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5616591270 | ||||||||
| FaxNumber: | 5618045629 | ||||||||
| Practice Location | |||||||||
| Address1: | 39200 HOOKER HWY | ||||||||
| Address2: | |||||||||
| City: | BELLE GLADE | ||||||||
| State: | FL | ||||||||
| PostalCode: | 33430 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5619966571 | ||||||||
| FaxNumber: | 5619962898 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/07/2008 | ||||||||
| LastUpdateDate: | 11/05/2019 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | DAVIS | ||||||||
| AuthorizedOfficialFirstName: | DARCY | ||||||||
| AuthorizedOfficialMiddleName: | J. | ||||||||
| AuthorizedOfficialTitleorPosition: | CEO | ||||||||
| AuthorizedOfficialTelephone: | 5616591270 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | HEALTH CARE DISTRICT OF PALM BEACH COUNTY | ||||||||
| AuthorizedOfficialNamePrefix: | MS. | ||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208600000X | ME88565 | FL | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Surgery |
ID Information
| ID | Type | State | Issuer | Description | 263720100 | 05 | FL | MEDICAID | 352226306 | 01 | FL | UNHC | OTHER | 27017 | 01 | FL | BCBS OF FL | OTHER | 50283 | 01 | FL | BCBS OF FL | OTHER | 57748 | 01 | FL | BCBS OF FL | OTHER | 61206 | 01 | FL | BCBS OF FL | OTHER | 96470 | 01 | FL | BCBS OF FL | OTHER | 07172 | 01 | FL | BCBS OF FL | OTHER | 273098700 | 05 | FL | MEDICAID | 374891000 | 05 | FL | MEDICAID | 000353300 | 05 | FL | MEDICAID | 048319200 | 05 | FL | MEDICAID | 066569000 | 05 | FL | MEDICAID | 275845800 | 05 | FL | MEDICAID | 31944 | 01 | FL | BCBS OF FL | OTHER | 001218400 | 05 | FL | MEDICAID | 11487 | 01 | FL | BCBS OF FL | OTHER | 145PH | 01 | FL | BCBS OF FL | OTHER | 50791 | 01 | FL | BCBS OF FL | OTHER | 257949900 | 05 | FL | MEDICAID | 27628 | 01 | FL | BCBS OF FL | OTHER | 277386400 | 05 | FL | MEDICAID | 043885500 | 05 | FL | MEDICAID | 23945 | 01 | FL | BCBS OF FL | OTHER | 270147200 | 05 | FL | MEDICAID | 271390000 | 05 | FL | MEDICAID | 255840800 | 05 | FL | MEDICAID |