Provider Demographics
NPI:1528367711
Name:DELRAY ADVANCED MEDICAL GROUP LLC
Entity Type:Organization
Organization Name:DELRAY ADVANCED MEDICAL GROUP LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:MS
Authorized Official - First Name:SALLY
Authorized Official - Middle Name:
Authorized Official - Last Name:BERRY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:561-330-6640
Mailing Address - Street 1:30 SE 6TH ST
Mailing Address - Street 2:
Mailing Address - City:BOCA RATON
Mailing Address - State:FL
Mailing Address - Zip Code:33432-6016
Mailing Address - Country:US
Mailing Address - Phone:561-948-1915
Mailing Address - Fax:561-344-6822
Practice Address - Street 1:30 SE 6TH ST
Practice Address - Street 2:
Practice Address - City:BOCA RATON
Practice Address - State:FL
Practice Address - Zip Code:33432-6016
Practice Address - Country:US
Practice Address - Phone:561-948-1915
Practice Address - Fax:561-344-6822
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-03-28
Last Update Date:2011-10-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME487462084N0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2084N0400XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurologyGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLD27065Medicare UPIN
FL73303Medicare PIN