Provider Demographics
NPI:1710620885
Name:PALM MEDICAL CENTER LAKELAND LLC
Entity Type:Organization
Organization Name:PALM MEDICAL CENTER LAKELAND LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CREDENTIALING MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:CARMEL
Authorized Official - Middle Name:N
Authorized Official - Last Name:BOSWELL
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:813-538-7880
Mailing Address - Street 1:5258 LINTON BLVD STE 301
Mailing Address - Street 2:
Mailing Address - City:DELRAY BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:33484-6539
Mailing Address - Country:US
Mailing Address - Phone:561-819-5447
Mailing Address - Fax:561-819-5496
Practice Address - Street 1:5258 LINTON BLVD STE 301
Practice Address - Street 2:
Practice Address - City:DELRAY BEACH
Practice Address - State:FL
Practice Address - Zip Code:33484-6539
Practice Address - Country:US
Practice Address - Phone:561-819-5447
Practice Address - Fax:561-819-5496
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:PALM MEDICAL CENTER LAKELAND LLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2022-04-18
Last Update Date:2022-04-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
No261Q00000XAmbulatory Health Care FacilitiesClinic/CenterGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL276547100Medicaid