Provider Demographics
NPI:1760456172
Name:MARK AND KAMBOUR MD PA
Entity Type:Organization
Organization Name:MARK AND KAMBOUR MD PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CFO
Authorized Official - Prefix:
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:
Authorized Official - Last Name:GRATTENDICK
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:561-514-5822
Mailing Address - Street 1:11025 RCA CENTER DR STE 300
Mailing Address - Street 2:
Mailing Address - City:PALM BEACH GARDENS
Mailing Address - State:FL
Mailing Address - Zip Code:33410-4269
Mailing Address - Country:US
Mailing Address - Phone:561-514-5822
Mailing Address - Fax:
Practice Address - Street 1:16250 NW 59TH AVE STE 201
Practice Address - Street 2:
Practice Address - City:MIAMI LAKES
Practice Address - State:FL
Practice Address - Zip Code:33014-7542
Practice Address - Country:US
Practice Address - Phone:305-825-4422
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-02-14
Last Update Date:2020-03-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME35872207ZC0500X, 207ZP0102X, 207ZP0105X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207ZP0102XAllopathic & Osteopathic PhysiciansPathologyAnatomic Pathology & Clinical PathologyGroup - Multi-Specialty
No207ZC0500XAllopathic & Osteopathic PhysiciansPathologyCytopathologyGroup - Multi-Specialty
No207ZP0105XAllopathic & Osteopathic PhysiciansPathologyClinical Pathology/Laboratory MedicineGroup - Multi-Specialty