Provider Demographics
NPI:1497925895
Name:MARK E GONWA MD PLLC TEAM RADIOLOGY
Entity Type:Organization
Organization Name:MARK E GONWA MD PLLC TEAM RADIOLOGY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:MARK
Authorized Official - Middle Name:E
Authorized Official - Last Name:GONWA
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:516-625-8584
Mailing Address - Street 1:4440 PGA BLVD
Mailing Address - Street 2:SUITE 402
Mailing Address - City:PALM BEACH GARDENS
Mailing Address - State:FL
Mailing Address - Zip Code:33410-6539
Mailing Address - Country:US
Mailing Address - Phone:516-625-8584
Mailing Address - Fax:
Practice Address - Street 1:2500 HARBOR BLVD
Practice Address - Street 2:
Practice Address - City:PORT CHARLOTTE
Practice Address - State:FL
Practice Address - Zip Code:33952-5000
Practice Address - Country:US
Practice Address - Phone:941-766-4382
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-03-03
Last Update Date:2008-08-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME643112085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic RadiologyGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLF75287Medicare UPIN
FLAK328Medicare PIN
FL23820Medicare PIN