Healthcare Provider Details

I. General information

NPI: 1073275897
Provider Name (Legal Business Name): PALM BEACH GENERAL SURGERY LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/08/2021
Last Update Date: 10/08/2021
Certification Date: 10/08/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

21110 BISCAYNE BLVD STE 400
AVENTURA FL
33180-1252
US

IV. Provider business mailing address

2000 HEALTH PARK DR
BRENTWOOD TN
37027-4692
US

V. Phone/Fax

Practice location:
  • Phone: 302-285-5092
  • Fax:
Mailing address:
  • Phone: 615-372-5426
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2086X0206X
TaxonomySurgical Oncology Physician
License Number
License Number State

VIII. Authorized Official

Name: WILLIAM TEDRICK JOHNSON
Title or Position: VICE PRESIDENT
Credential:
Phone: 615-372-3375