MEDICARE: PALM BEACH NEUROSURGERY 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	207T00000X	Neurological Surgery Physician

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	74721	OTHER		BCBS OF FL

General Provider Information

NPI Number	:	1649218561
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	PALM BEACH NEUROSURGERY LLC

Provider Business Mailing Address
First Line	:	5507 S CONGRESS AVE
Second Line	:	SUITE 150
City	:	ATLANTIS
State	:	FL
Zip	:	33462-1139
Country	:	US
Telephone Number	:	561-433-4444
Fax Number	:	561-433-8877

Provider Business Practice Location Address
First Line	:	5507 S CONGRESS AVE
Second Line	:	SUITE 150
City	:	ATLANTIS
State	:	FL
Zip	:	33462-1139
Country	:	US
Telephone Number	:	561-433-4444
Fax Number	:	561-433-8877

Authorized Official
Title or Position	:	VICE PRESIDENT
Name	:	GARY DUNCAN
Credential	:
Telephone Number	:	561-433-4444

Provider Enumeration Date	:	06/03/2006
Last Update Date	:	08/29/2007

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