MEDICARE: PHYSICIANS IMMEDIATE CARE SOUTHWEST, LLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	261QU0200X	Urgent Care Clinic/Center	HCC5630	FL

General Provider Information

NPI Number	:	1063808301
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	PHYSICIANS IMMEDIATE CARE SOUTHWEST, LLC

Provider Business Mailing Address
First Line	:	4007 SW PORT ST LUCIE BLVD
Second Line	:
City	:	PORT ST LUCIE
State	:	FL
Zip	:	34953-5679
Country	:	US
Telephone Number	:	772-343-1774
Fax Number	:	772-343-1744

Provider Business Practice Location Address
First Line	:	4007 SW PORT ST LUCIE BLVD
Second Line	:
City	:	PORT ST LUCIE
State	:	FL
Zip	:	34953-5679
Country	:	US
Telephone Number	:	772-343-1774
Fax Number	:	772-343-1744

Authorized Official
Title or Position	:	CEO
Name	:	KENNETH PALESTRANT
Credential	:	M.D.
Telephone Number	:	772-343-1776

Provider Enumeration Date	:	04/14/2015
Last Update Date	:	04/14/2015

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