Healthcare Provider Details

I. General information

NPI: 1376883587
Provider Name (Legal Business Name): GOSPA MEDICAL GROUP, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/25/2013
Last Update Date: 03/27/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3452 W BOYNTON BEACH BLVD STE. 5
BOYNTON BEACH FL
33436-4633
US

IV. Provider business mailing address

3452 W BOYNTON BEACH BLVD STE. 5
BOYNTON BEACH FL
33436-4633
US

V. Phone/Fax

Practice location:
  • Phone: 561-299-0910
  • Fax:
Mailing address:
  • Phone: 561-299-0910
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number
License Number State

VIII. Authorized Official

Name: MRS. JACQUELINE FARBER
Title or Position: MGRM
Credential:
Phone: 561-299-0910