Basic Information
| Provider Information | |||||||||
| NPI: | 1437184009 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | JUPITER EMERGENCY MEDICAL SPECIALIST INC | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 2699 | ||||||||
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| City: | JUPITER | ||||||||
| State: | FL | ||||||||
| PostalCode: | 334682699 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5617482889 | ||||||||
| FaxNumber: | 5617481523 | ||||||||
| Practice Location | |||||||||
| Address1: | 1210 S OLD DIXIE HWY | ||||||||
| Address2: | |||||||||
| City: | JUPITER | ||||||||
| State: | FL | ||||||||
| PostalCode: | 334587205 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5617482889 | ||||||||
| FaxNumber: | 5617481523 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/12/2006 | ||||||||
| LastUpdateDate: | 12/17/2009 | ||||||||
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| AuthorizedOfficialLastName: | COLLINS | ||||||||
| AuthorizedOfficialFirstName: | CHARLES | ||||||||
| AuthorizedOfficialMiddleName: | MICHAEL | ||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 5617482889 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | M.D. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207P00000X | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Emergency Medicine |
No ID Information.