Provider Demographics
NPI:1629259072
Name:PALM BEACH PEDIATRICS
Entity Type:Organization
Organization Name:PALM BEACH PEDIATRICS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRACTICE ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:KIMBERLY
Authorized Official - Middle Name:
Authorized Official - Last Name:BRENNAN
Authorized Official - Suffix:
Authorized Official - Credentials:MBA, CMPE
Authorized Official - Phone:561-509-5009
Mailing Address - Street 1:1920 PALM BEACH LAKES BLVD STE 201
Mailing Address - Street 2:
Mailing Address - City:WEST PALM BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:33409-3506
Mailing Address - Country:US
Mailing Address - Phone:561-509-5009
Mailing Address - Fax:561-738-1822
Practice Address - Street 1:13475 SOUTHERN BLVD STE 202
Practice Address - Street 2:
Practice Address - City:LOXAHATCHEE GROVES
Practice Address - State:FL
Practice Address - Zip Code:33470-9233
Practice Address - Country:US
Practice Address - Phone:561-798-2468
Practice Address - Fax:561-798-2733
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-11-14
Last Update Date:2022-11-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Single Specialty
No103T00000XBehavioral Health & Social Service ProvidersPsychologistGroup - Single Specialty
No363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental HealthGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL379641800Medicaid