=====================================================
General NPI Number Information
=====================================================
NPI Number | 1255679031
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | ANTHEM MEDICAL MANAGEMENT INC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/29/2013
-----------------------------------------------------
Last Update Date | 01/29/2013
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1483 S FEDERAL HWY
-----------------------------------------------------
City | BOYNTON BEACH
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33435-6003
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 561-629-7267
-----------------------------------------------------
Fax | 561-629-7954
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1483 S FEDERAL HWY
-----------------------------------------------------
City | BOYNTON BEACH
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33435-6003
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 561-629-7267
-----------------------------------------------------
Fax | 561-629-7954
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | DR. MOISE W ANGLADE
-----------------------------------------------------
Credential | MD
-----------------------------------------------------
Telephone | 561-629-7267
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 302R00000X
-----------------------------------------------------
Taxonomy Name | Health Maintenance Organization
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------