Provider Demographics
NPI:1447266085
Name:PULMONOLOGY AND SLEEP CENTER LLC
Entity type:Organization
Organization Name:PULMONOLOGY AND SLEEP CENTER LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGING MEMBER
Authorized Official - Prefix:
Authorized Official - First Name:FREDERICK
Authorized Official - Middle Name:
Authorized Official - Last Name:TACKEY
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:561-374-8919
Mailing Address - Street 1:PO BOX 550
Mailing Address - Street 2:
Mailing Address - City:BOYNTON BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:33425-0550
Mailing Address - Country:US
Mailing Address - Phone:561-374-8919
Mailing Address - Fax:581-374-8911
Practice Address - Street 1:2300 SOUTH CONGRESS AVENUE SUITE 101
Practice Address - Street 2:
Practice Address - City:BOYNTON BEACH
Practice Address - State:FL
Practice Address - Zip Code:33426
Practice Address - Country:US
Practice Address - Phone:561-374-8911
Practice Address - Fax:561-374-8911
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-01
Last Update Date:2012-10-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL0068055207R00000X, 207RC0200X, 207RP1001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RP1001XAllopathic & Osteopathic PhysiciansInternal MedicinePulmonary DiseaseGroup - Single Specialty
No207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
No207RC0200XAllopathic & Osteopathic PhysiciansInternal MedicineCritical Care MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL377890800Medicaid
FL377890800Medicaid
F71810Medicare UPIN