Provider Demographics
NPI:1588983944
Name:PMC PALMETTO BAY CORP.
Entity type:Organization
Organization Name:PMC PALMETTO BAY CORP.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DOCTOR
Authorized Official - Prefix:MRS
Authorized Official - First Name:OLIVE
Authorized Official - Middle Name:
Authorized Official - Last Name:CHUNG-JAMES
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:305-251-3975
Mailing Address - Street 1:9275 S.W. 152 STREET
Mailing Address - Street 2:SUITE 204
Mailing Address - City:MIAMI
Mailing Address - State:FL
Mailing Address - Zip Code:33157
Mailing Address - Country:US
Mailing Address - Phone:305-251-3975
Mailing Address - Fax:
Practice Address - Street 1:9275 S.W. 152 STREET
Practice Address - Street 2:SUITE 204
Practice Address - City:MIAMI
Practice Address - State:FL
Practice Address - Zip Code:33157
Practice Address - Country:US
Practice Address - Phone:305-251-3975
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:PMC PALMETTO BAY, CORP
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2010-05-25
Last Update Date:2012-11-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME42907207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL94420AMedicare PIN