1205928587 NPI number — PEDIATRIX MEDICAL GROUP PC

Table of content: (NPI 1205928587)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1205928587 NPI number — PEDIATRIX MEDICAL GROUP PC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
PEDIATRIX MEDICAL GROUP PC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1205928587
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
10/20/2023
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
4991 LAKE BROOK DR
Provider Second Line Business Mailing Address:
SUITE 300
Provider Business Mailing Address City Name:
GLEN ALLEN
Provider Business Mailing Address State Name:
VA
Provider Business Mailing Address Postal Code:
23060-9293
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
804-346-3535
Provider Business Mailing Address Fax Number:
804-253-0408

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1301 CONCORD TER
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
SUNRISE
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
33323-2843
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
954-384-0175
Provider Business Practice Location Address Fax Number:
954-851-1948
Provider Enumeration Date:
09/28/2006

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
KASPAR
Authorized Official First Name:
DEBRA
Authorized Official Middle Name:
Authorized Official Title or Position:
ASSISTANT SECRETARY
Authorized Official Telephone Number:
954-384-0175

Provider Taxonomy Codes

  • Taxonomy code: 208000000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 2080N0001X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 1205928587 , issued by the state of ( VA ) . This identifiers is of the category "MEDICAID".