Healthcare Provider Details

I. General information

NPI: 1225301526
Provider Name (Legal Business Name): JUPITER MEDICAL GROUP P A
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/16/2012
Last Update Date: 02/16/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

875 MILITARY TRL SUITE 208
JUPITER FL
33458-5700
US

IV. Provider business mailing address

875 MILITARY TRL SUITE 200
JUPITER FL
33458-5700
US

V. Phone/Fax

Practice location:
  • Phone: 561-746-2411
  • Fax: 561-745-7333
Mailing address:
  • Phone: 561-746-2411
  • Fax: 561-745-7333

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License NumberME0049954
License Number StateFL
# 2
Primary TaxonomyN
Taxonomy Code207RC0000X
TaxonomyCardiovascular Disease Physician
License NumberME0076025
License Number StateFL
# 3
Primary TaxonomyN
Taxonomy Code207RG0300X
TaxonomyGeriatric Medicine (Internal Medicine) Physician
License NumberME0049954
License Number StateFL

VIII. Authorized Official

Name: DR. RAJENDRA L BANSAL
Title or Position: MEDICAL DIRECTOR
Credential: M.D.
Phone: 561-746-2411