Provider Demographics
NPI:1568912699
Name:SOMA MEDICAL CENTER, PA #4
Entity Type:Organization
Organization Name:SOMA MEDICAL CENTER, PA #4
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:LINA NIEMCZYK
Authorized Official - Middle Name:
Authorized Official - Last Name:NIEMCZYK
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:561-433-0080
Mailing Address - Street 1:4623 FOREST HILL BLVD
Mailing Address - Street 2:SUITE 112
Mailing Address - City:WEST PALM BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:33415-7469
Mailing Address - Country:US
Mailing Address - Phone:561-433-0080
Mailing Address - Fax:561-433-1668
Practice Address - Street 1:4623 FOREST HILL BLVD
Practice Address - Street 2:SUITE 112
Practice Address - City:WEST PALM BEACH
Practice Address - State:FL
Practice Address - Zip Code:33415-7469
Practice Address - Country:US
Practice Address - Phone:561-433-0080
Practice Address - Fax:561-433-1668
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:SOMA MEDICAL CENTER, PA #4
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2016-10-13
Last Update Date:2021-04-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME102127208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Single Specialty