1477007318 NPI number — PEDIATRIC SPECIALTY GROUP, INC.

Table of content: (NPI 1477007318)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1477007318 NPI number — PEDIATRIC SPECIALTY GROUP, INC.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
PEDIATRIC SPECIALTY GROUP, INC.
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:
PEDIATRIC SPECIALISTS OF AMERICA- RHEUMATOLOGY
Provider Other Organization Name Type Code:
3
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:
1477007318
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
03/03/2021
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 865095
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
ORLANDO
Provider Business Mailing Address State Name:
FL
Provider Business Mailing Address Postal Code:
32886-5095
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
786-624-5876
Provider Business Mailing Address Fax Number:
786-624-2688

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
3100 SW 62ND AVE
Provider Second Line Business Practice Location Address:
SUITE 105
Provider Business Practice Location Address City Name:
MIAMI
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
33155
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
786-624-5876
Provider Business Practice Location Address Fax Number:
786-624-2688
Provider Enumeration Date:
08/09/2016

Additional Information

Authorized Official

Authorized Official Last Name:
GABER
Authorized Official First Name:
LAURA
Authorized Official Middle Name:
M
Authorized Official Title or Position:
PROVIDER RELATIONS SPECIALIST
Authorized Official Telephone Number:
786-624-5747

Provider Taxonomy Codes

  • Taxonomy code: 2080P0216X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 013515206 , issued by the state of ( FL ) . This identifiers is of the category "MEDICAID".




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