MEDICARE: PRESERVATION PARK EMERGENCY PHYSICIANS, 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	207P00000X	Emergency Medicine Physician

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1144898321
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	PRESERVATION PARK EMERGENCY PHYSICIANS, LLC

Provider Business Mailing Address
First Line	:	5565 CENTERVIEW DR STE 107
Second Line	:
City	:	RALEIGH
State	:	NC
Zip	:	27606-3563
Country	:	US
Telephone Number	:	973-251-1132
Fax Number	:

Provider Business Practice Location Address
First Line	:	10921 S JOG RD STE 156
Second Line	:
City	:	BOYNTON BEACH
State	:	FL
Zip	:	33437-4002
Country	:	US
Telephone Number	:	561-548-8250
Fax Number	:

Authorized Official
Title or Position	:	AO
Name	:	KATHLEEN MARIE KONDAS
Credential	:
Telephone Number	:	973-251-1132

Provider Enumeration Date	:	06/15/2021
Last Update Date	:	06/15/2021

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