Provider Demographics
NPI:1780906909
Name:ADVANCED BREAST CARE OF THE PALM BEACHES, PA.
Entity type:Organization
Organization Name:ADVANCED BREAST CARE OF THE PALM BEACHES, PA.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:KATHLEEN
Authorized Official - Middle Name:E
Authorized Official - Last Name:MINNICK
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:561-798-7494
Mailing Address - Street 1:125 S STATE ROAD 7
Mailing Address - Street 2:SUITE 104-363
Mailing Address - City:WELLINGTON
Mailing Address - State:FL
Mailing Address - Zip Code:33414-4385
Mailing Address - Country:US
Mailing Address - Phone:561-798-7494
Mailing Address - Fax:978-327-7952
Practice Address - Street 1:12160 S SHORE BLVD
Practice Address - Street 2:SUITE 103
Practice Address - City:WELLINGTON
Practice Address - State:FL
Practice Address - Zip Code:33414-6269
Practice Address - Country:US
Practice Address - Phone:561-798-7494
Practice Address - Fax:978-327-7952
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-02-16
Last Update Date:2010-08-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME78137208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208600000XAllopathic & Osteopathic PhysiciansSurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL05-27-2010OtherCIGNA
FL05-15-2010OtherGHI
FL07-06-2005OtherAVMED
FL03-01-2010OtherMEDICARE
FL03-31-2005OtherBCBS
FL02-04-2010OtherUNITED
FL04-01-2010OtherAETNA