Provider Demographics
NPI:1376883587
Name:GOSPA MEDICAL GROUP, LLC
Entity Type:Organization
Organization Name:GOSPA MEDICAL GROUP, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MGRM
Authorized Official - Prefix:MRS
Authorized Official - First Name:JACQUELINE
Authorized Official - Middle Name:
Authorized Official - Last Name:FARBER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:561-299-0910
Mailing Address - Street 1:3452 W BOYNTON BEACH BLVD
Mailing Address - Street 2:STE. 5
Mailing Address - City:BOYNTON BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:33436-4633
Mailing Address - Country:US
Mailing Address - Phone:561-299-0910
Mailing Address - Fax:
Practice Address - Street 1:3452 W BOYNTON BEACH BLVD
Practice Address - Street 2:STE. 5
Practice Address - City:BOYNTON BEACH
Practice Address - State:FL
Practice Address - Zip Code:33436-4633
Practice Address - Country:US
Practice Address - Phone:561-299-0910
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-02-25
Last Update Date:2013-03-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
No208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Single Specialty