MEDICARE: JUPITER LAKES PHYSICIAN GROUP PA

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	261QP2300X	Primary Care Clinic/Center

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	:	1154969699
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	JUPITER LAKES PHYSICIAN GROUP PA

Provider Business Mailing Address
First Line	:	210 JUPITER LAKES BLVD STE 4104
Second Line	:
City	:	JUPITER
State	:	FL
Zip	:	33458-7190
Country	:	US
Telephone Number	:	561-744-3467
Fax Number	:	561-748-3272

Provider Business Practice Location Address
First Line	:	210 JUPITER LAKES BLVD STE 4104
Second Line	:
City	:	JUPITER
State	:	FL
Zip	:	33458-7190
Country	:	US
Telephone Number	:	561-744-3467
Fax Number	:	561-748-3272

Authorized Official
Title or Position	:	ADMINISTRATOR
Name	:	MICHELLE FULLER
Credential	:
Telephone Number	:	561-398-3661

Provider Enumeration Date	:	12/16/2019
Last Update Date	:	12/16/2019

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