Healthcare Provider Details

I. General information

NPI: 1003098088
Provider Name (Legal Business Name): JANE E BISTLINE MD PA
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/30/2007
Last Update Date: 12/13/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2047 PALM BEACH LAKES BLVD SUITE 300
WEST PALM BEACH FL
33401-6500
US

IV. Provider business mailing address

2047 PALM BEACH LAKES BLVD SUITE 300
WEST PALM BEACH FL
33401-6500
US

V. Phone/Fax

Practice location:
  • Phone: 561-681-9808
  • Fax: 561-681-9989
Mailing address:
  • Phone: 561-681-9808
  • Fax: 561-681-9989

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code174400000X
TaxonomySpecialist
License NumberME64772
License Number StateFL

VIII. Authorized Official

Name: JANE E BISTLINE
Title or Position: PRESIDENT
Credential:
Phone: 561-681-9808