Provider Demographics
NPI:1558812560
Name:PALM SPRINGS MEDICAL GROUP LLC
Entity Type:Organization
Organization Name:PALM SPRINGS MEDICAL GROUP LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGING PARTNER
Authorized Official - Prefix:
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:J
Authorized Official - Last Name:LANDRY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:786-233-8722
Mailing Address - Street 1:1380 NE MIAMI GARDENS DR
Mailing Address - Street 2:SUITE 210
Mailing Address - City:N MIAMI BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:33179-4707
Mailing Address - Country:US
Mailing Address - Phone:305-692-9009
Mailing Address - Fax:305-541-4220
Practice Address - Street 1:1490 W 49TH PL
Practice Address - Street 2:SUITE 506
Practice Address - City:HIALEAH
Practice Address - State:FL
Practice Address - Zip Code:33012-3148
Practice Address - Country:US
Practice Address - Phone:305-692-9009
Practice Address - Fax:305-541-4220
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-10-14
Last Update Date:2016-10-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral PracticeGroup - Multi-Specialty