Provider Demographics
NPI:1902930795
Name:PALM BEACH SURGICAL ASSOCIATES
Entity Type:Organization
Organization Name:PALM BEACH SURGICAL ASSOCIATES
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:AGUSTIN
Authorized Official - Middle Name:
Authorized Official - Last Name:IBARROLA
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:561-331-0808
Mailing Address - Street 1:6415 LAKE WORTH RD STE 102
Mailing Address - Street 2:
Mailing Address - City:GREENACRES
Mailing Address - State:FL
Mailing Address - Zip Code:33463-3009
Mailing Address - Country:US
Mailing Address - Phone:561-331-0808
Mailing Address - Fax:561-237-6034
Practice Address - Street 1:120 JFK DR STE 120
Practice Address - Street 2:
Practice Address - City:ATLANTIS
Practice Address - State:FL
Practice Address - Zip Code:33462-6623
Practice Address - Country:US
Practice Address - Phone:561-331-0808
Practice Address - Fax:561-594-0880
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-15
Last Update Date:2022-06-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208600000XAllopathic & Osteopathic PhysiciansSurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL24344OtherFLORIDA BLUE
FL000892200Medicaid
FL000892200Medicaid