Basic Information
Provider Information | |||||||||
NPI: | 1578669917 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | FLORIDA COMMUNITY HEALTH CENTERS INC | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: | NORTH PALM BEACH INFECTIOUS DISEASE CENTER | ||||||||
OtherOrganizationType: | 5 | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
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: | 4450 S TIFFANY DR | ||||||||
Address2: |   | ||||||||
City: | WEST PALM BEACH | ||||||||
State: | FL | ||||||||
PostalCode: | 334073241 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 5618449443 | ||||||||
FaxNumber: | 5618441013 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 09/15/2006 | ||||||||
LastUpdateDate: | 09/06/2011 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | GERVASI | ||||||||
AuthorizedOfficialFirstName: | MICHAEL | ||||||||
AuthorizedOfficialMiddleName: | F | ||||||||
AuthorizedOfficialTitleorPosition: | PRESIDENT & CEO | ||||||||
AuthorizedOfficialTelephone: | 5618449443 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: | DR. | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: | D.O. | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363AM0700X |   |   | N | 193200000X MULTI-SPECIALTY GROUP | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | Medical | 261QF0400X |   |   | N |   | Ambulatory Health Care Facilities | Clinic/Center | Federally Qualified Health Center (FQHC) | 207RI0200X |   |   | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine | Infectious Disease |
ID Information
ID | Type | State | Issuer | Description | 029574417 | 05 | FL |   | MEDICAID | 029574416 | 05 | FL |   | MEDICAID |