Provider Demographics
NPI:1619178001
Name:JUPITER PRIMARY CARE GROUP INC
Entity Type:Organization
Organization Name:JUPITER PRIMARY CARE GROUP INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:MICHELLE
Authorized Official - Middle Name:
Authorized Official - Last Name:FATIMA FULLER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:561-629-2990
Mailing Address - Street 1:210 JUPITER LAKES BLVD
Mailing Address - Street 2:BUILDING 4000 SUITE 105
Mailing Address - City:JUPITER
Mailing Address - State:FL
Mailing Address - Zip Code:33458-7191
Mailing Address - Country:US
Mailing Address - Phone:561-743-9077
Mailing Address - Fax:561-745-6529
Practice Address - Street 1:210 JUPITER LAKES BLVD
Practice Address - Street 2:BUILDING 4000 SUITE 105
Practice Address - City:JUPITER
Practice Address - State:FL
Practice Address - Zip Code:33458-7191
Practice Address - Country:US
Practice Address - Phone:561-743-9077
Practice Address - Fax:561-745-6529
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-31
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty