Provider Demographics
NPI:1548545601
Name:PRACTITIONER MEDICAL SERVICES INC
Entity type:Organization
Organization Name:PRACTITIONER MEDICAL SERVICES INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:MARIE
Authorized Official - Middle Name:MICHELLE
Authorized Official - Last Name:CARNER
Authorized Official - Suffix:
Authorized Official - Credentials:ARNP
Authorized Official - Phone:561-843-2325
Mailing Address - Street 1:22274 SW 61ST AVE
Mailing Address - Street 2:
Mailing Address - City:BOCA RATON
Mailing Address - State:FL
Mailing Address - Zip Code:33428-4410
Mailing Address - Country:US
Mailing Address - Phone:561-843-2325
Mailing Address - Fax:561-483-6266
Practice Address - Street 1:3075 NW 35TH AVE
Practice Address - Street 2:
Practice Address - City:LAUDERDALE LAKES
Practice Address - State:FL
Practice Address - Zip Code:33311-1107
Practice Address - Country:US
Practice Address - Phone:561-843-2325
Practice Address - Fax:561-483-6266
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-10-19
Last Update Date:2012-09-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLP11000009589261QP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLFO938AMedicare PIN