MEDICARE: HEALTHY SENIOR MEDICAL GROUP 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	208D00000X	General Practice Physician

General Provider Information

NPI Number	:	1194327379
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	HEALTHY SENIOR MEDICAL GROUP LLC

Provider Business Mailing Address
First Line	:	2199 NE 5TH AVE
Second Line	:
City	:	BOCA RATON
State	:	FL
Zip	:	33431-7610
Country	:	US
Telephone Number	:	561-702-1299
Fax Number	:	561-584-7505

Provider Business Practice Location Address
First Line	:	515 E LAS OLAS BLVD STE 120
Second Line	:
City	:	FORT LAUDERDALE
State	:	FL
Zip	:	33301-4261
Country	:	US
Telephone Number	:	954-787-8874
Fax Number	:	954-787-8875

Authorized Official
Title or Position	:	CEO
Name	:	CHRISTOPHER J PETTAS
Credential	:
Telephone Number	:	561-702-1299

Provider Enumeration Date	:	11/12/2020
Last Update Date	:	11/12/2020

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