=====================================================
General NPI Number Information
=====================================================
NPI Number | 1245539071
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | DISSICK MEDICAL ASSOCIATES,PA
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/18/2011
-----------------------------------------------------
Last Update Date | 04/05/2011
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 7301A PALMETTO PARK ROAD SUITE 301A
-----------------------------------------------------
City | BOCA RATON
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33433
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 561-672-7950
-----------------------------------------------------
Fax | 561-672-7953
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 7301A PALMETTO PARK ROAD SUITE 301A
-----------------------------------------------------
City | BOCA RATON
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33433
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 561-672-7950
-----------------------------------------------------
Fax | 561-672-7953
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | DR. ADDIE DISSICK
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 561-672-7950
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207R00000X
-----------------------------------------------------
Taxonomy Name | Internal Medicine Physician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------