Provider Demographics
NPI:1710183744
Name:PALM BEACH MEDICAL CLINIC LLC
Entity Type:Organization
Organization Name:PALM BEACH MEDICAL CLINIC LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CHIEF EXECUTIVE OFFICER OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:STEPHEN
Authorized Official - Middle Name:KWASHIE
Authorized Official - Last Name:WOYOME
Authorized Official - Suffix:
Authorized Official - Credentials:MD,
Authorized Official - Phone:561-584-4142
Mailing Address - Street 1:13833 WELLINGTON TRCE
Mailing Address - Street 2:E4-#204
Mailing Address - City:WELLINGTON
Mailing Address - State:FL
Mailing Address - Zip Code:33414-2116
Mailing Address - Country:US
Mailing Address - Phone:561-584-4142
Mailing Address - Fax:
Practice Address - Street 1:9123 N MILITARY TRL
Practice Address - Street 2:SUITE 102
Practice Address - City:WEST PALM BEACH
Practice Address - State:FL
Practice Address - Zip Code:33410-5990
Practice Address - Country:US
Practice Address - Phone:561-630-9339
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-06-26
Last Update Date:2008-05-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME9587207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLAH265OtherMEDICARE PTAN