Provider Demographics
NPI:1912368556
Name:ROYAL PALM PHYSICIAN GROUP, PA
Entity Type:Organization
Organization Name:ROYAL PALM PHYSICIAN GROUP, PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:KELLY
Authorized Official - Middle Name:A
Authorized Official - Last Name:FONTANA
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:239-451-3143
Mailing Address - Street 1:1585 PINE RIDGE RD STE 2
Mailing Address - Street 2:
Mailing Address - City:NAPLES
Mailing Address - State:FL
Mailing Address - Zip Code:34109-2105
Mailing Address - Country:US
Mailing Address - Phone:239-451-3143
Mailing Address - Fax:239-451-3145
Practice Address - Street 1:1585 PINE RIDGE RD STE 2
Practice Address - Street 2:
Practice Address - City:NAPLES
Practice Address - State:FL
Practice Address - Zip Code:34109-2105
Practice Address - Country:US
Practice Address - Phone:239-451-3143
Practice Address - Fax:239-451-3145
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-03-10
Last Update Date:2016-03-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME98117208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral PracticeGroup - Single Specialty