Provider Demographics
NPI:1487985610
Name:ROYAL PALM MEDICAL GROUP INC
Entity type:Organization
Organization Name:ROYAL PALM MEDICAL GROUP INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:LAZARO
Authorized Official - Middle Name:
Authorized Official - Last Name:GONZALEZ
Authorized Official - Suffix:
Authorized Official - Credentials:APRN
Authorized Official - Phone:239-313-6300
Mailing Address - Street 1:2665 CLEVELAND AVE STE 102
Mailing Address - Street 2:
Mailing Address - City:FORT MYERS
Mailing Address - State:FL
Mailing Address - Zip Code:33901-5884
Mailing Address - Country:US
Mailing Address - Phone:239-313-6300
Mailing Address - Fax:239-689-5524
Practice Address - Street 1:2665 CLEVELAND AVE STE 102
Practice Address - Street 2:
Practice Address - City:FORT MYERS
Practice Address - State:FL
Practice Address - Zip Code:33901-5884
Practice Address - Country:US
Practice Address - Phone:239-313-6300
Practice Address - Fax:239-689-5524
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-01-28
Last Update Date:2021-02-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLMM24026261QP2000X
207Q00000X, 261Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/Center
No261QP2000XAmbulatory Health Care FacilitiesClinic/CenterPhysical TherapyGroup - Multi-Specialty
No207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty