Basic Information
| Provider Information | |||||||||
| NPI: | 1861700833 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | GASTRO GROUP OF THE PALM BEACHES LLP | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2001 N FLAGLER DR | ||||||||
| Address2: | |||||||||
| City: | WEST PALM BEACH | ||||||||
| State: | FL | ||||||||
| PostalCode: | 334076109 | ||||||||
| CountryCode: | US | ||||||||
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| Address1: | 2001 N FLAGLER DR | ||||||||
| Address2: | |||||||||
| City: | WEST PALM BEACH | ||||||||
| State: | FL | ||||||||
| PostalCode: | 334076109 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5616596543 | ||||||||
| FaxNumber: | 5616593533 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/23/2010 | ||||||||
| LastUpdateDate: | 08/11/2020 | ||||||||
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| AuthorizedOfficialLastName: | BOLOGNINI | ||||||||
| AuthorizedOfficialFirstName: | LISA | ||||||||
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| AuthorizedOfficialTitleorPosition: | CHIEF OPERATING OFFICER | ||||||||
| AuthorizedOfficialTelephone: | 5616596632 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MRS. | ||||||||
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| NPICertificationDate: | 08/11/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207RG0100X | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine | Gastroenterology |
ID Information
| ID | Type | State | Issuer | Description | 002990900 | 05 | FL | MEDICAID |