Provider Demographics
NPI:1700088911
Name:SEACREST MEDICAL GROUP PA
Entity Type:Organization
Organization Name:SEACREST MEDICAL GROUP PA
Other - Org Name:SEACREST MEDICAL OFFICE DIAGNOSTIC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PHYSICIAN
Authorized Official - Prefix:
Authorized Official - First Name:JEAN
Authorized Official - Middle Name:RICHARD
Authorized Official - Last Name:ETIENNE
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:561-738-7611
Mailing Address - Street 1:2848 S SEACREST BLVD
Mailing Address - Street 2:
Mailing Address - City:BOYNTON BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:33435-7935
Mailing Address - Country:US
Mailing Address - Phone:561-738-7611
Mailing Address - Fax:561-738-7622
Practice Address - Street 1:2848 S SEACREST BLVD
Practice Address - Street 2:
Practice Address - City:BOYNTON BEACH
Practice Address - State:FL
Practice Address - Zip Code:33435-7935
Practice Address - Country:US
Practice Address - Phone:561-738-7611
Practice Address - Fax:561-738-7622
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-06-01
Last Update Date:2020-10-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME94948207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL=========OtherTAX IDENTIFICATION
FL=========OtherTAX IDENTIFICATION