Provider Demographics
NPI:1235313917
Name:JUPITER MEDICAL GROUP P A
Entity Type:Organization
Organization Name:JUPITER MEDICAL GROUP P A
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:RAJENDRA
Authorized Official - Middle Name:K
Authorized Official - Last Name:BANSAL
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:561-746-2411
Mailing Address - Street 1:875 MILITARY TRL
Mailing Address - Street 2:SUITE 200
Mailing Address - City:JUPITER
Mailing Address - State:FL
Mailing Address - Zip Code:33458-5700
Mailing Address - Country:US
Mailing Address - Phone:561-746-2411
Mailing Address - Fax:561-354-0012
Practice Address - Street 1:19 SE OSCEOLA ST
Practice Address - Street 2:
Practice Address - City:STUART
Practice Address - State:FL
Practice Address - Zip Code:34994-2125
Practice Address - Country:US
Practice Address - Phone:772-283-4093
Practice Address - Fax:772-283-9874
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-12-18
Last Update Date:2007-12-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLK2421Medicare PIN