Healthcare Provider Details

I. General information

NPI: 1255352787
Provider Name (Legal Business Name): BEN THEBAUT M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/21/2006
Last Update Date: 04/28/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2580 METROCENTRE BLVD SUITE 1
WEST PALM BEACH FL
33407-3100
US

IV. Provider business mailing address

PO BOX 11
JUPITER FL
33468-0011
US

V. Phone/Fax

Practice location:
  • Phone: 561-684-2022
  • Fax:
Mailing address:
  • Phone: 561-748-2889
  • Fax: 561-748-1523

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207XS0106X
TaxonomyOrthopaedic Hand Surgery Physician
License NumberME20057
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: