Provider Demographics
NPI:1891980389
Name:PALM BAY URGENT CARE PL
Entity Type:Organization
Organization Name:PALM BAY URGENT CARE PL
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:STANLEY
Authorized Official - Middle Name:F
Authorized Official - Last Name:DZIEDZIC
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:212-734-6621
Mailing Address - Street 1:1155 MALABAR RD NE STE 10
Mailing Address - Street 2:
Mailing Address - City:PALM BAY
Mailing Address - State:FL
Mailing Address - Zip Code:32907-3262
Mailing Address - Country:US
Mailing Address - Phone:321-723-3627
Mailing Address - Fax:
Practice Address - Street 1:1155 MALABAR RD NE STE 10
Practice Address - Street 2:
Practice Address - City:PALM BAY
Practice Address - State:FL
Practice Address - Zip Code:32907-3262
Practice Address - Country:US
Practice Address - Phone:321-723-3627
Practice Address - Fax:321-723-1771
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-09-08
Last Update Date:2024-02-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261QU0200XAmbulatory Health Care FacilitiesClinic/CenterUrgent CareGroup - Single Specialty
No261QX0100XAmbulatory Health Care FacilitiesClinic/CenterOccupational Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLME79869OtherMEDICAL LICENSE NUMBER