Provider Demographics
NPI:1497977599
Name:PRODIGY MEDICAL PROFESSIONALS, LLC
Entity Type:Organization
Organization Name:PRODIGY MEDICAL PROFESSIONALS, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGING MEMBER (CO-OWNER)
Authorized Official - Prefix:MS
Authorized Official - First Name:ANDREA
Authorized Official - Middle Name:(NONE)
Authorized Official - Last Name:PINE-GRIMALDI
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:561-512-6057
Mailing Address - Street 1:1621 RIPLEY RUN
Mailing Address - Street 2:
Mailing Address - City:WELLINGTON
Mailing Address - State:FL
Mailing Address - Zip Code:33414
Mailing Address - Country:US
Mailing Address - Phone:561-512-6057
Mailing Address - Fax:561-204-5093
Practice Address - Street 1:1621 RIPLEY RUN
Practice Address - Street 2:
Practice Address - City:WELLINGTON
Practice Address - State:FL
Practice Address - Zip Code:33414
Practice Address - Country:US
Practice Address - Phone:561-512-6057
Practice Address - Fax:561-204-5093
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-02
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLOT11509171W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes171W00000XOther Service ProvidersContractorGroup - Multi-Specialty