Provider Demographics
NPI:1730485897
Name:MDPREVENT MEDICAL GROUP PA
Entity Type:Organization
Organization Name:MDPREVENT MEDICAL GROUP PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CHIEF SERVICE OFFICER
Authorized Official - Prefix:DR
Authorized Official - First Name:STEVEN
Authorized Official - Middle Name:S
Authorized Official - Last Name:CHARLAP
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:617-319-6434
Mailing Address - Street 1:5130 LINTON BLVD
Mailing Address - Street 2:H-1
Mailing Address - City:DELRAY BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:33484-6596
Mailing Address - Country:US
Mailing Address - Phone:561-807-2561
Mailing Address - Fax:561-537-8221
Practice Address - Street 1:5130 LINTON BLVD
Practice Address - Street 2:H-1
Practice Address - City:DELRAY BEACH
Practice Address - State:FL
Practice Address - Zip Code:33484-6596
Practice Address - Country:US
Practice Address - Phone:561-807-2561
Practice Address - Fax:561-537-8221
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-02-07
Last Update Date:2011-11-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
103T00000X, 133V00000X, 261QP2300X
FLME899472083P0901X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care
No103T00000XBehavioral Health & Social Service ProvidersPsychologistGroup - Single Specialty
No133V00000XDietary & Nutritional Service ProvidersDietitian, RegisteredGroup - Single Specialty
No2083P0901XAllopathic & Osteopathic PhysiciansPreventive MedicinePublic Health & General Preventive MedicineGroup - Single Specialty