MEDICARE: PALM BEACH CHILDREN'S ASSOCIATES, P.A.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	208000000X	Pediatrics Physician	ME 0055058	FL

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	015509	OTHER	FL	AETNA
2	38361	OTHER	FL	BLUE CROSS BLUE SHIELD

General Provider Information

NPI Number	:	1871714394
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	PALM BEACH CHILDREN'S ASSOCIATES, P.A.

Provider Business Mailing Address
First Line	:	1860 FOREST HILL BLVD
Second Line	:	STE 102
City	:	WEST PALM BEACH
State	:	FL
Zip	:	33406-6086
Country	:	US
Telephone Number	:	561-641-6000
Fax Number	:	561-641-6006

Provider Business Practice Location Address
First Line	:	1860 FOREST HILL BLVD
Second Line	:	STE 102
City	:	WEST PALM BEACH
State	:	FL
Zip	:	33406-6086
Country	:	US
Telephone Number	:	561-641-6000
Fax Number	:	561-641-6006

Authorized Official
Title or Position	:	PRESIDENT
Name	:	DR. CONRAD VALENTINO WYNNE JR.
Credential	:	M.D.
Telephone Number	:	561-641-6000

Provider Enumeration Date	:	05/01/2007
Last Update Date	:	08/22/2020

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