Provider Demographics
NPI:1114963006
Name:PAUL E GREGOLINE DPM PA
Entity Type:Organization
Organization Name:PAUL E GREGOLINE DPM PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PODIATRIC SURGEON
Authorized Official - Prefix:DR
Authorized Official - First Name:PAUL
Authorized Official - Middle Name:EUGENE
Authorized Official - Last Name:GREGOLINE
Authorized Official - Suffix:
Authorized Official - Credentials:DPM
Authorized Official - Phone:954-793-2387
Mailing Address - Street 1:1865 S OCEAN DR
Mailing Address - Street 2:15 I
Mailing Address - City:HALLANDALE BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:33009-7603
Mailing Address - Country:US
Mailing Address - Phone:954-457-5539
Mailing Address - Fax:954-457-5539
Practice Address - Street 1:45 NW 4TH ST
Practice Address - Street 2:
Practice Address - City:HOMESTEAD
Practice Address - State:FL
Practice Address - Zip Code:33030-5941
Practice Address - Country:US
Practice Address - Phone:786-259-3239
Practice Address - Fax:305-246-8556
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-21
Last Update Date:2009-10-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPO2877213ES0103X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL340156101Medicaid
FLDN9281OtherRAILROAD MEDICARE NUMBER GROUP
FLDN9281OtherRAILROAD MEDICARE NUMBER GROUP
FL340156101Medicaid
FL6152960001Medicare NSC