Provider Demographics
NPI:1942519277
Name:BOYNTON MEDICAL GROUP INC
Entity Type:Organization
Organization Name:BOYNTON MEDICAL GROUP INC
Other - Org Name:AMICUS MEDICAL GROUP
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:DAVID
Authorized Official - Middle Name:R
Authorized Official - Last Name:RODRIGUEZ
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:954-505-5000
Mailing Address - Street 1:14201 W SUNRISE BLVD
Mailing Address - Street 2:SUITE 207
Mailing Address - City:SUNRISE
Mailing Address - State:FL
Mailing Address - Zip Code:33323-3207
Mailing Address - Country:US
Mailing Address - Phone:954-505-5000
Mailing Address - Fax:954-838-9660
Practice Address - Street 1:1501 CORPORATE DR
Practice Address - Street 2:
Practice Address - City:BOYNTON BEACH
Practice Address - State:FL
Practice Address - Zip Code:33426-6600
Practice Address - Country:US
Practice Address - Phone:561-369-4255
Practice Address - Fax:561-369-3254
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-10-05
Last Update Date:2015-04-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME91277207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLF1240AMedicare PIN