Provider Demographics
NPI:1073570511
Name:PALM HARBOR INTERNAL MEDICINE AND PEDIATRICS, PA
Entity Type:Organization
Organization Name:PALM HARBOR INTERNAL MEDICINE AND PEDIATRICS, PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT OF CORPORATION
Authorized Official - Prefix:DR
Authorized Official - First Name:GARY
Authorized Official - Middle Name:M
Authorized Official - Last Name:GOLDSTEIN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:727-789-5811
Mailing Address - Street 1:3890 TAMPA RD
Mailing Address - Street 2:SUITE 101
Mailing Address - City:PALM HARBOR
Mailing Address - State:FL
Mailing Address - Zip Code:34684-3676
Mailing Address - Country:US
Mailing Address - Phone:727-789-5811
Mailing Address - Fax:727-786-8417
Practice Address - Street 1:3890 TAMPA RD
Practice Address - Street 2:SUITE 101
Practice Address - City:PALM HARBOR
Practice Address - State:FL
Practice Address - Zip Code:34684-3676
Practice Address - Country:US
Practice Address - Phone:727-789-5811
Practice Address - Fax:727-786-8417
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-04-27
Last Update Date:2013-10-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty
No208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLK3566Medicare ID - Type Unspecified