1215063821 NPI number — PEDIATRIC HEALTH CARE

Table of content: (NPI 1215063821)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1215063821 NPI number — PEDIATRIC HEALTH CARE

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
PEDIATRIC HEALTH CARE
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 HEALTH CARE
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:
1215063821
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
03/01/2012
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
5308 S JOHN YOUNG PKWY
Provider Second Line Business Mailing Address:
SUITE 200
Provider Business Mailing Address City Name:
ORLANDO
Provider Business Mailing Address State Name:
FL
Provider Business Mailing Address Postal Code:
32839-7362
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
407-563-2821
Provider Business Mailing Address Fax Number:
407-240-9508

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
5308 S JOHN YOUNG PKWY
Provider Second Line Business Practice Location Address:
STE. 200
Provider Business Practice Location Address City Name:
ORLANDO
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
32839-7362
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
407-563-2821
Provider Business Practice Location Address Fax Number:
407-240-9508
Provider Enumeration Date:
02/26/2007

Additional Information

Authorized Official

Authorized Official Last Name:
ALI
Authorized Official First Name:
RAZA
Authorized Official Middle Name:
Authorized Official Title or Position:
PHYSICIAN
Authorized Official Telephone Number:
407-563-2821

Provider Taxonomy Codes

  • Taxonomy code: 208000000X , with the licence number:  ME 62109 , registered in the state of FL ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 266317100 . This is a "Florida Medicaid Provider ID" identifier , issued by the state of ( FL ) . This identifiers is of the category "MEDICAID".




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