Provider Demographics
NPI:1881096071
Name:WILHELM C J LARSEN MD PA
Entity type:Organization
Organization Name:WILHELM C J LARSEN MD PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER, PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:WILHELM
Authorized Official - Middle Name:CHARLES JOSEPH
Authorized Official - Last Name:LARSEN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:561-707-4161
Mailing Address - Street 1:PO BOX 220688
Mailing Address - Street 2:3900 HARVERHILL ROAD NORTH
Mailing Address - City:WEST PALM BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:33422-0688
Mailing Address - Country:US
Mailing Address - Phone:561-707-4161
Mailing Address - Fax:561-791-2128
Practice Address - Street 1:351 POTTER RD
Practice Address - Street 2:
Practice Address - City:WEST PALM BEACH
Practice Address - State:FL
Practice Address - Zip Code:33405-3621
Practice Address - Country:US
Practice Address - Phone:561-707-4161
Practice Address - Fax:561-908-2604
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-09-19
Last Update Date:2016-04-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME0027507283Q00000X, 282N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes282N00000XHospitalsGeneral Acute Care Hospital
No283Q00000XHospitalsPsychiatric Hospital
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL0447382Medicaid
FL0447382Medicaid