Healthcare Provider Details

I. General information

NPI: 1033169107
Provider Name (Legal Business Name): KIDNEY & DIALYSIS SPECIALISTS OF THE PALM BEACHES, PA
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/11/2006
Last Update Date: 09/14/2023
Certification Date: 09/14/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5305 GREENWOOD AVE STE 102
WEST PALM BEACH FL
33407-2448
US

IV. Provider business mailing address

5305 GREENWOOD AVE STE 102
WEST PALM BEACH FL
33407-2448
US

V. Phone/Fax

Practice location:
  • Phone: 561-840-7779
  • Fax:
Mailing address:
  • Phone: 561-840-7779
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RN0300X
TaxonomyNephrology Physician
License NumberME75515
License Number StateFL

VIII. Authorized Official

Name: MRS. MICHELLE KATHERINE GAMMACK-CLARK
Title or Position: OFFICE MANAGER
Credential:
Phone: 561-840-7779