Healthcare Provider Details

I. General information

NPI: 1144593435
Provider Name (Legal Business Name): PRESERVATION PARK EMERGENCY PHYSICIANS, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/16/2012
Last Update Date: 12/22/2020
Certification Date: 12/22/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

13001 SOUTHERN BLVD
LOXAHATCHEE FL
33470-9203
US

IV. Provider business mailing address

PO BOX 37859
PHILADELPHIA PA
19101-0159
US

V. Phone/Fax

Practice location:
  • Phone: 561-798-3300
  • Fax: 561-798-6064
Mailing address:
  • Phone: 954-838-2371
  • Fax: 610-834-2862

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number
License Number State

VIII. Authorized Official

Name: KATHLEEN KONDAS
Title or Position: OFFICER
Credential:
Phone: 973-251-1132