Healthcare Provider Details

I. General information

NPI: 1932879848
Provider Name (Legal Business Name): GENERAL SURGERY OF JUPITER MEDICAL SPECIALISTS, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/14/2021
Last Update Date: 09/14/2021
Certification Date: 08/30/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3602 KYOTO GARDENS DR
WEST PALM BEACH FL
33410-2713
US

IV. Provider business mailing address

5565 CENTERVIEW DR STE 107
RALEIGH NC
27606-3563
US

V. Phone/Fax

Practice location:
  • Phone: 877-328-1119
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208600000X
TaxonomySurgery Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code2086S0127X
TaxonomyTrauma Surgery Physician
License Number
License Number State

VIII. Authorized Official

Name: KATHLEEN KONDAS
Title or Position: OFFICER
Credential:
Phone: 877-328-1119