Provider Demographics
NPI:1477558203
Name:GASTROENTEROLOGY GROUP OF THE PALM BEACHES, PA
Entity Type:Organization
Organization Name:GASTROENTEROLOGY GROUP OF THE PALM BEACHES, PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATIVE DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:LISA
Authorized Official - Middle Name:
Authorized Official - Last Name:BOLOGNINI
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:561-659-6632
Mailing Address - Street 1:2001 N FLAGLER DR
Mailing Address - Street 2:
Mailing Address - City:WEST PALM BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:33407-6109
Mailing Address - Country:US
Mailing Address - Phone:561-659-6543
Mailing Address - Fax:561-659-3533
Practice Address - Street 1:2001 N FLAGLER DR
Practice Address - Street 2:
Practice Address - City:WEST PALM BEACH
Practice Address - State:FL
Practice Address - Zip Code:33407-6109
Practice Address - Country:US
Practice Address - Phone:561-659-6543
Practice Address - Fax:561-659-3533
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-06-17
Last Update Date:2009-11-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME0043419207RG0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RG0100XAllopathic & Osteopathic PhysiciansInternal MedicineGastroenterologyGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL042147200Medicaid
FL72165Medicare PIN