=====================================================
General NPI Number Information
=====================================================
NPI Number | 1902930795
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | PALM BEACH SURGICAL ASSOCIATES
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/15/2007
-----------------------------------------------------
Last Update Date | 06/01/2022
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 120 JFK DR STE 120
-----------------------------------------------------
City | ATLANTIS
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33462-6623
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 561-331-0808
-----------------------------------------------------
Fax | 561-594-0880
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 6415 LAKE WORTH RD STE 102
-----------------------------------------------------
City | GREENACRES
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33463-3009
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 561-331-0808
-----------------------------------------------------
Fax | 561-237-6034
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | AGUSTIN IBARROLA
-----------------------------------------------------
Credential | M.D.
-----------------------------------------------------
Telephone | 561-331-0808
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 208600000X
-----------------------------------------------------
Taxonomy Name | Surgery Physician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------