MEDICARE: PALM MEDICAL CENTER LAKELAND 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	:	1942154133
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	PALM MEDICAL CENTER LAKELAND LLC

Provider Business Mailing Address
First Line	:	2600 S DOUGLAS RD STE 308
Second Line	:
City	:	CORAL GABLES
State	:	FL
Zip	:	33134-6134
Country	:	US
Telephone Number	:	305-913-9454
Fax Number	:	305-442-1198

Provider Business Practice Location Address
First Line	:	613 W DR MARTIN LUTHER KING JR BLVD
Second Line	:
City	:	TAMPA
State	:	FL
Zip	:	33603-3400
Country	:	US
Telephone Number	:	813-237-1958
Fax Number	:	813-237-8147

Authorized Official
Title or Position	:	CREDENTIALING MANAGER
Name	:	CARMEL N BOSWELL
Credential	:
Telephone Number	:	813-538-7880

Provider Enumeration Date	:	02/24/2026
Last Update Date	:	02/24/2026

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