Prodigy Medical Professionals, LLC

Primary specialty

ContractorTaxonomy code 171W00000X

License

OT11509 Issued in FL

Legal business name

PRODIGY MEDICAL PROFESSIONALS, LLC

Practice address

1621 Ripley Run
Wellington, FL 33414

Phone

(561) 512-6057

Fax

(561) 204-5093

NPI assigned

May 2, 2007

Organization subpart

No

Registry information is reported by the provider to CMS and is not verified. About this source

Authorized official

Name

Ms. Andrea (None) Pine-Grimaldi

Title

Managing Member (Co-Owner)

Phone

(561) 512-6057

Specialties & licenses 1

Addresses

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1178064000000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1598054400000",
    "number": "1497977599",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "1621 RIPLEY RUN",
            "city": "WELLINGTON",
            "state": "FL",
            "postal_code": "33414",
            "telephone_number": "561-512-6057",
            "fax_number": "561-204-5093"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "1621 RIPLEY RUN",
            "city": "WELLINGTON",
            "state": "FL",
            "postal_code": "33414",
            "telephone_number": "561-512-6057",
            "fax_number": "561-204-5093"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "PRODIGY MEDICAL PROFESSIONALS, LLC",
        "organizational_subpart": "NO",
        "enumeration_date": "2007-05-02",
        "last_updated": "2020-08-22",
        "status": "A",
        "authorized_official_last_name": "PINE-GRIMALDI",
        "authorized_official_first_name": "ANDREA",
        "authorized_official_middle_name": "(NONE)",
        "authorized_official_title_or_position": "MANAGING MEMBER (CO-OWNER)",
        "authorized_official_telephone_number": "561-512-6057",
        "authorized_official_name_prefix": "Ms."
    },
    "taxonomies": [
        {
            "code": "171W00000X",
            "taxonomy_group": "193200000X MULTI-SPECIALTY GROUP",
            "desc": "Contractor",
            "state": "FL",
            "license": "OT11509",
            "primary": true
        }
    ],
    "identifiers": [],
    "endpoints": [],
    "other_names": []
}

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• Contractor in Wellington, FL
• Providers in Wellington, FL by specialty
• Contractor in Florida

• NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Aug 22, 2020; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
• National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.