Provider Demographics
NPI:1275309932
Name:DIVERSE MEDICAL PROFESSIONALS, PA
Entity type:Organization
Organization Name:DIVERSE MEDICAL PROFESSIONALS, PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICIAN/MEDICAL DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:RYAN
Authorized Official - Middle Name:
Authorized Official - Last Name:ROSEN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:561-509-9382
Mailing Address - Street 1:1200 S FEDERAL HWY STE 302
Mailing Address - Street 2:
Mailing Address - City:BOYNTON BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:33435-6058
Mailing Address - Country:US
Mailing Address - Phone:561-509-9382
Mailing Address - Fax:561-509-9362
Practice Address - Street 1:1200 S FEDERAL HWY STE 302
Practice Address - Street 2:
Practice Address - City:BOYNTON BEACH
Practice Address - State:FL
Practice Address - Zip Code:33435-6058
Practice Address - Country:US
Practice Address - Phone:561-509-9382
Practice Address - Fax:561-509-9362
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-12-04
Last Update Date:2023-12-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty
No208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & RehabilitationGroup - Multi-Specialty
No208VP0000XAllopathic & Osteopathic PhysiciansPain MedicinePain MedicineGroup - Multi-Specialty