=====================================================
General NPI Number Information
=====================================================
NPI Number | 1083088579
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | PALMERS URGENT CARE AND DIAGNOSTICS INC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 11/20/2015
-----------------------------------------------------
Last Update Date | 03/17/2017
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 5409 N STATE ROAD 7
-----------------------------------------------------
City | TAMARAC
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33319-2921
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 954-526-9477
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 5409 N STATE ROAD 7
-----------------------------------------------------
City | TAMARAC
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33319-2921
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 954-526-9477
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | JEAN ROBERT CHARLOT
-----------------------------------------------------
Credential | M.D
-----------------------------------------------------
Telephone | 954-526-9477
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207V00000X
-----------------------------------------------------
Taxonomy Name | Obstetrics & Gynecology Physician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 261QU0200X
-----------------------------------------------------
Taxonomy Name | Urgent Care Clinic/Center
-----------------------------------------------------
License Number | ME 79727
-----------------------------------------------------
License Number State | FL
-----------------------------------------------------
Taxonomy #3
-----------------------------------------------------
Taxonomy Code | 111N00000X
-----------------------------------------------------
Taxonomy Name | Chiropractor
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #4
-----------------------------------------------------
Taxonomy Code | 207Q00000X
-----------------------------------------------------
Taxonomy Name | Family Medicine Physician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------