Provider Demographics
NPI:1093026619
Name:FLORIDA ATLANTIC UNIVERSITY
Entity type:Organization
Organization Name:FLORIDA ATLANTIC UNIVERSITY
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:LOUISA
Authorized Official - Middle Name:
Authorized Official - Last Name:PONTIROLI KELLY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:561-803-8880
Mailing Address - Street 1:1650 OSCEOLA DRIVE
Mailing Address - Street 2:
Mailing Address - City:WEST PALM BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:33409
Mailing Address - Country:US
Mailing Address - Phone:561-803-8880
Mailing Address - Fax:877-409-1795
Practice Address - Street 1:1650 OSCEOLA DRIVE
Practice Address - Street 2:
Practice Address - City:WEST PALM BEACH
Practice Address - State:FL
Practice Address - Zip Code:33409
Practice Address - Country:US
Practice Address - Phone:561-803-8880
Practice Address - Fax:877-409-1795
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:FLORIDA ATLANTIC UNIVERSITY
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2010-06-29
Last Update Date:2025-01-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261QF0400XAmbulatory Health Care FacilitiesClinic/CenterFederally Qualified Health Center (FQHC)Group - Multi-Specialty
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGroup - Multi-Specialty
No363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental HealthGroup - Multi-Specialty
No363LP2300XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPrimary CareGroup - Multi-Specialty
No207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL002Z8OtherBCBS
FLK3331COtherMEDICARE
FL303078400Medicaid
FL681903OtherFQHC MEDICARE 2021 FOR BOTH 1650 AND 720 LOCATIONS
FL112255000OtherFQHC MEDICAID 2021 FOR 1650 ONLY
FL303078411Medicaid