Provider Demographics
NPI:1508047952
Name:PALM BEACH PEDIATRICS, PA
Entity Type:Organization
Organization Name:PALM BEACH PEDIATRICS, PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRACTICE ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:KIMBERLY
Authorized Official - Middle Name:
Authorized Official - Last Name:BRENNAN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:561-509-5009
Mailing Address - Street 1:1920 PALM BEACH LAKES BLVD STE 201
Mailing Address - Street 2:
Mailing Address - City:WEST PALM BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:33409-3506
Mailing Address - Country:US
Mailing Address - Phone:561-509-5009
Mailing Address - Fax:561-738-1822
Practice Address - Street 1:4700 N CONGRESS AVE STE 201
Practice Address - Street 2:
Practice Address - City:WEST PALM BEACH
Practice Address - State:FL
Practice Address - Zip Code:33407-3291
Practice Address - Country:US
Practice Address - Phone:561-509-5009
Practice Address - Fax:561-471-4278
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:PALM BEACH PEDIATRICS, PA
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2007-11-14
Last Update Date:2023-09-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL379641801Medicaid