Provider Demographics
NPI:1396211421
Name:FLORIDA ATLANTIC UNIVERSITY
Entity Type:Organization
Organization Name:FLORIDA ATLANTIC UNIVERSITY
Other - Org Name:COLLEGE OF MEDICINE CLINIC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:AUTHORIZED OFFICIAL
Authorized Official - Prefix:
Authorized Official - First Name:LOUISA
Authorized Official - Middle Name:
Authorized Official - Last Name:PONTIROLI-KELLY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:561-297-2897
Mailing Address - Street 1:777 GLADES ROAD
Mailing Address - Street 2:COLLEGE OF MEDICINE, BC-71, FINANCE OFFICE
Mailing Address - City:BOCA RATON
Mailing Address - State:FL
Mailing Address - Zip Code:33431
Mailing Address - Country:US
Mailing Address - Phone:561-566-5328
Mailing Address - Fax:
Practice Address - Street 1:880 NW 13TH ST STE 400
Practice Address - Street 2:
Practice Address - City:BOCA RATON
Practice Address - State:FL
Practice Address - Zip Code:33486-2342
Practice Address - Country:US
Practice Address - Phone:561-297-4814
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-10-16
Last Update Date:2024-03-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
No207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty