Healthcare Provider Details

I. General information

NPI: 1710444583
Provider Name (Legal Business Name): SOUTHEAST UNIVERSITY PHYSICIANS PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/27/2019
Last Update Date: 07/22/2024
Certification Date: 07/22/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2560 RCA BLVD STE 106
PALM BEACH GARDENS FL
33410-3336
US

IV. Provider business mailing address

2560 RCA BLVD STE 106
PALM BEACH GARDENS FL
33410-3336
US

V. Phone/Fax

Practice location:
  • Phone: 561-799-9559
  • Fax: 561-799-9577
Mailing address:
  • Phone: 561-799-9559
  • Fax: 561-799-9577

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207RC0200X
TaxonomyCritical Care Medicine (Internal Medicine) Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code208600000X
TaxonomySurgery Physician
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code2086S0102X
TaxonomySurgical Critical Care Physician
License Number
License Number State

VIII. Authorized Official

Name: KATHRYN NOLAND
Title or Position: PRACTICE MANAGER
Credential:
Phone: 561-799-9559