Healthcare Provider Details

I. General information

NPI: 1073570511
Provider Name (Legal Business Name): PALM HARBOR INTERNAL MEDICINE AND PEDIATRICS, PA
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/27/2006
Last Update Date: 10/02/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3890 TAMPA RD SUITE 101
PALM HARBOR FL
34684-3676
US

IV. Provider business mailing address

3890 TAMPA RD SUITE 101
PALM HARBOR FL
34684-3676
US

V. Phone/Fax

Practice location:
  • Phone: 727-789-5811
  • Fax: 727-786-8417
Mailing address:
  • Phone: 727-789-5811
  • Fax: 727-786-8417

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: DR. GARY M GOLDSTEIN
Title or Position: PRESIDENT OF CORPORATION
Credential: M.D.
Phone: 727-789-5811