Provider Demographics
NPI:1215092697
Name:NORTHLAKE MEDICAL CENTER
Entity type:Organization
Organization Name:NORTHLAKE MEDICAL CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:ROBERT
Authorized Official - Middle Name:WILLIAM
Authorized Official - Last Name:MACKLER
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:561-626-9192
Mailing Address - Street 1:4300 NORTHLAKE BLVD
Mailing Address - Street 2:
Mailing Address - City:PALM BEACH GARDENS
Mailing Address - State:FL
Mailing Address - Zip Code:33410-6254
Mailing Address - Country:US
Mailing Address - Phone:561-626-9190
Mailing Address - Fax:561-626-7274
Practice Address - Street 1:4300 NORTHLAKE BLVD
Practice Address - Street 2:
Practice Address - City:PALM BEACH GARDENS
Practice Address - State:FL
Practice Address - Zip Code:33410-6254
Practice Address - Country:US
Practice Address - Phone:561-626-9190
Practice Address - Fax:561-626-7274
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-26
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLME39831OtherMEDICAL LICENSE NUMBER
FLD65255Medicare UPIN
FLME39831OtherMEDICAL LICENSE NUMBER