Provider Demographics
| NPI: | 1407022601 |
|---|---|
| Name: | HEALTH CARE DISTRICT OF PALM BEACH COUNTY |
| Entity Type: | Organization |
| Organization Name: | HEALTH CARE DISTRICT OF PALM BEACH COUNTY |
| Other - Org Name: | LAKESIDE PHYSICIAN PRACTICE |
| Other - Org Type: | Doing Business As |
| Authorized Official - Title/Position: | CEO |
| Authorized Official - Prefix: | MS |
| Authorized Official - First Name: | DARCY |
| Authorized Official - Middle Name: | J |
| Authorized Official - Last Name: | DAVIS |
| Authorized Official - Suffix: | |
| Authorized Official - Credentials: | |
| Authorized Official - Phone: | 561-659-1270 |
| Mailing Address - Street 1: | 1515 N FLAGLER DR STE 101 |
| Mailing Address - Street 2: | |
| Mailing Address - City: | WEST PALM BEACH |
| Mailing Address - State: | FL |
| Mailing Address - Zip Code: | 33401-3429 |
| Mailing Address - Country: | US |
| Mailing Address - Phone: | 561-659-1270 |
| Mailing Address - Fax: | 561-804-5629 |
| Practice Address - Street 1: | 39200 HOOKER HWY |
| Practice Address - Street 2: | |
| Practice Address - City: | BELLE GLADE |
| Practice Address - State: | FL |
| Practice Address - Zip Code: | 33430 |
| Practice Address - Country: | US |
| Practice Address - Phone: | 561-996-6571 |
| Practice Address - Fax: | 561-996-2898 |
| EIN: | <UNAVAIL> |
| Is Organization Subpart?: | Yes |
| Parent Organization LBN: | HEALTH CARE DISTRICT OF PALM BEACH COUNTY |
| Parent Organization TIN: | <UNAVAIL> |
| Enumeration Date: | 2008-05-07 |
| Last Update Date: | 2019-11-05 |
| Deactivation Date: | |
| Deactivation Code: | |
| Reactivation Date: |
Provider Licenses
| State | License ID | Taxonomies |
|---|---|---|
| FL | ME88565 | 208600000X, 208600000X |
| FL | ME75318 | 207R00000X |
| FL | ME61252 | 207R00000X |
| FL | ME93651 | 207R00000X |
| FL | ME61532 | 207RC0000X |
| FL | ME89191 | 207RC0000X |
| FL | ME79386 | 207RC0000X |
| FL | ME38526 | 207RC0000X |
| FL | ME89631 | 207RC0000X |
| FL | ME97686 | 207V00000X |
| FL | ME103537 | 207V00000X |
| FL | ME70645 | 207Y00000X |
| FL | ME45616 | 2080N0001X |
| FL | ME35369 | 208600000X |
Provider Taxonomies
| Primary? | Code | Type | Classification | Specialization | Group |
|---|---|---|---|---|---|
| Yes | 208600000X | Allopathic & Osteopathic Physicians | Surgery | Group - Single Specialty | |
| No | 207R00000X | Allopathic & Osteopathic Physicians | Internal Medicine | Group - Multi-Specialty | |
| No | 207RC0000X | Allopathic & Osteopathic Physicians | Internal Medicine | Cardiovascular Disease | Group - Multi-Specialty |
| No | 207V00000X | Allopathic & Osteopathic Physicians | Obstetrics & Gynecology | Group - Multi-Specialty | |
| No | 207Y00000X | Allopathic & Osteopathic Physicians | Otolaryngology | Group - Multi-Specialty | |
| No | 2080N0001X | Allopathic & Osteopathic Physicians | Pediatrics | Neonatal-Perinatal Medicine | Group - Multi-Specialty |
Provider Identifiers
| State | Identifier ID | ID Type | Issuer |
|---|---|---|---|
| FL | 263720100 | Medicaid | |
| FL | 352226306 | Other | UNHC |
| FL | 27017 | Other | BCBS OF FL |
| FL | 50283 | Other | BCBS OF FL |
| FL | 57748 | Other | BCBS OF FL |
| FL | 61206 | Other | BCBS OF FL |
| FL | 96470 | Other | BCBS OF FL |
| FL | 07172 | Other | BCBS OF FL |
| FL | 273098700 | Medicaid | |
| FL | 374891000 | Medicaid | |
| FL | 000353300 | Medicaid | |
| FL | 048319200 | Medicaid | |
| FL | 066569000 | Medicaid | |
| FL | 275845800 | Medicaid | |
| FL | 31944 | Other | BCBS OF FL |
| FL | 001218400 | Medicaid | |
| FL | 11487 | Other | BCBS OF FL |
| FL | 145PH | Other | BCBS OF FL |
| FL | 50791 | Other | BCBS OF FL |
| FL | 257949900 | Medicaid | |
| FL | 27628 | Other | BCBS OF FL |
| FL | 277386400 | Medicaid | |
| FL | 043885500 | Medicaid | |
| FL | 23945 | Other | BCBS OF FL |
| FL | 270147200 | Medicaid | |
| FL | 271390000 | Medicaid | |
| FL | 255840800 | Medicaid | |
| FL | 96470 | Other | BCBS OF FL |
