Healthcare Provider Details

I. General information

NPI: 1477558203
Provider Name (Legal Business Name): GASTROENTEROLOGY GROUP OF THE PALM BEACHES, PA
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/17/2005
Last Update Date: 11/30/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2001 N FLAGLER DR
WEST PALM BEACH FL
33407-6109
US

IV. Provider business mailing address

2001 N FLAGLER DR
WEST PALM BEACH FL
33407-6109
US

V. Phone/Fax

Practice location:
  • Phone: 561-659-6543
  • Fax: 561-659-3533
Mailing address:
  • Phone: 561-659-6543
  • Fax: 561-659-3533

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RG0100X
TaxonomyGastroenterology Physician
License NumberME0043419
License Number StateFL

VIII. Authorized Official

Name: LISA BOLOGNINI
Title or Position: ADMINISTRATIVE DIRECTOR
Credential:
Phone: 561-659-6632