Provider Demographics
NPI:1356504211
Name:PALM BEACH PLASTIC SURGERY PA
Entity Type:Organization
Organization Name:PALM BEACH PLASTIC SURGERY PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CREDENTIALING MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:JENNIFER
Authorized Official - Middle Name:
Authorized Official - Last Name:PRINS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:909-307-8503
Mailing Address - Street 1:641 UNIVERSITY BLVD
Mailing Address - Street 2:SUITE 103
Mailing Address - City:JUPITER
Mailing Address - State:FL
Mailing Address - Zip Code:33458-2791
Mailing Address - Country:US
Mailing Address - Phone:561-776-2830
Mailing Address - Fax:561-296-4156
Practice Address - Street 1:641 UNIVERSITY BLVD
Practice Address - Street 2:SUITE 103
Practice Address - City:JUPITER
Practice Address - State:FL
Practice Address - Zip Code:33458-2791
Practice Address - Country:US
Practice Address - Phone:561-776-2830
Practice Address - Fax:561-296-4156
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-07-09
Last Update Date:2009-04-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME84988208200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208200000XAllopathic & Osteopathic PhysiciansPlastic SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLK5990Medicare PIN