Basic Information
| Provider Information | |||||||||
| NPI: | 1659314854 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | MEDICAL SPECIALISTS OF THE PALM BEACHES INC | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | |||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | |||||||||
| Mailing Information | |||||||||
| Address1: | 5700 LAKE WORTH RD | ||||||||
| Address2: | #204 | ||||||||
| City: | GREENACRES | ||||||||
| State: | FL | ||||||||
| PostalCode: | 334634727 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5619687968 | ||||||||
| FaxNumber: | 5619644603 | ||||||||
| Practice Location | |||||||||
| Address1: | 5401 S CONGRESS AVE STE 102 | ||||||||
| Address2: | |||||||||
| City: | ATLANTIS | ||||||||
| State: | FL | ||||||||
| PostalCode: | 334626636 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5619675033 | ||||||||
| FaxNumber: | 5619675424 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/14/2006 | ||||||||
| LastUpdateDate: | 04/06/2022 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | WATERS | ||||||||
| AuthorizedOfficialFirstName: | CASEY | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | CEO | ||||||||
| AuthorizedOfficialTelephone: | 5616497000 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 04/06/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207RC0000X | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine | Cardiovascular Disease |
No ID Information.