Provider Demographics
NPI:1518220565
Name:PGL MEDICAL GROUP, PA
Entity Type:Organization
Organization Name:PGL MEDICAL GROUP, PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:VICE PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:GLENDESE
Authorized Official - Middle Name:C
Authorized Official - Last Name:MILLER
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:561-797-7653
Mailing Address - Street 1:108 INTRACOASTAL POINTE DR
Mailing Address - Street 2:SUITE 100
Mailing Address - City:JUPITER
Mailing Address - State:FL
Mailing Address - Zip Code:33477-5036
Mailing Address - Country:US
Mailing Address - Phone:561-575-3050
Mailing Address - Fax:561-575-3153
Practice Address - Street 1:108 INTRACOASTAL POINTE DR
Practice Address - Street 2:SUITE 100
Practice Address - City:JUPITER
Practice Address - State:FL
Practice Address - Zip Code:33477-5036
Practice Address - Country:US
Practice Address - Phone:561-575-3050
Practice Address - Fax:561-575-3153
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-06-24
Last Update Date:2012-06-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME104698207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty