MEDICARE: CORAL WAY MEDICAL CENTER INC

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	:	1427231562
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	CORAL WAY MEDICAL CENTER INC

Provider Business Mailing Address
First Line	:	1940 SE PORT ST LUCIE BLVD
Second Line	:
City	:	PORT ST LUCIE
State	:	FL
Zip	:	34952-5510
Country	:	US
Telephone Number	:	772-337-4430
Fax Number	:	772-337-4431

Provider Business Practice Location Address
First Line	:	1940 SE PORT ST LUCIE BLVD
Second Line	:
City	:	PORT ST LUCIE
State	:	FL
Zip	:	34952-5510
Country	:	US
Telephone Number	:	772-337-4430
Fax Number	:	772-337-4431

Authorized Official
Title or Position	:	PRESIDENT
Name	:	RONALD LUBETSKY
Credential	:	MD
Telephone Number	:	772-337-4430

Provider Enumeration Date	:	12/12/2007
Last Update Date	:	11/02/2009

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