Healthcare Provider Details

I. General information

NPI: 1427194968
Provider Name (Legal Business Name): PALM COAST INTERNAL MEDICINE PA
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/30/2007
Last Update Date: 09/04/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

21 HOSPITAL DR SUITE 280
PALM COAST FL
32164-2452
US

IV. Provider business mailing address

21 HOSPITAL DR SUITE 280
PALM COAST FL
32164-2452
US

V. Phone/Fax

Practice location:
  • Phone: 386-437-4711
  • Fax:
Mailing address:
  • Phone: 386-437-4711
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RA0000X
TaxonomyAdolescent Medicine (Internal Medicine) Physician
License NumberME78172
License Number StateFL

VIII. Authorized Official

Name: PHILIP GOODWIN
Title or Position: PRESIDENT
Credential: M.D.
Phone: 386-437-4711