Healthcare Provider Details

I. General information

NPI: 1295721389
Provider Name (Legal Business Name): SOUTH PALM GI PA
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/23/2005
Last Update Date: 12/13/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4675 LINTON BLVD SUITE 202
DELRAY BEACH FL
33445-6611
US

IV. Provider business mailing address

4675 LINTON BLVD SUITE 202
DELRAY BEACH FL
33445-6611
US

V. Phone/Fax

Practice location:
  • Phone: 561-495-5700
  • Fax: 561-495-2020
Mailing address:
  • Phone: 561-495-5700
  • Fax: 561-495-2020

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RG0100X
TaxonomyGastroenterology Physician
License Number
License Number State

VIII. Authorized Official

Name: MICHAEL LLOYD BLUM
Title or Position: PRESIDENT
Credential: M.D.
Phone: 561-495-5700