1376846733 NPI number — FLORIDA PEDIATRIC ASSOCIATES, LLC

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1376846733 NPI number — FLORIDA PEDIATRIC ASSOCIATES, LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
FLORIDA PEDIATRIC ASSOCIATES, LLC
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:
FLORIDA PEDIATRIC ASSOC OPTICAL MAITLAND
Provider Other Organization Name Type Code:
5
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:
1376846733
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
12/07/2010
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1033 DR MARTIN LUTHER KING JR ST N
Provider Second Line Business Mailing Address:
SUITE 108
Provider Business Mailing Address City Name:
ST PETERSBURG
Provider Business Mailing Address State Name:
FL
Provider Business Mailing Address Postal Code:
33701-1547
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
727-456-3288
Provider Business Mailing Address Fax Number:
727-456-3289

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
790 CONCOURSE PKWY S
Provider Second Line Business Practice Location Address:
SUITE 200
Provider Business Practice Location Address City Name:
MAITLAND
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
32751-6114
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
407-767-6411
Provider Business Practice Location Address Fax Number:
407-767-8160
Provider Enumeration Date:
12/07/2010

Additional Information

Authorized Official

Authorized Official Last Name:
TATHAM
Authorized Official First Name:
SHEILA
Authorized Official Middle Name:
A
Authorized Official Title or Position:
CREDENTIALING MANAGER
Authorized Official Telephone Number:
727-456-4250

Provider Taxonomy Codes

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

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

  • Identifier: 256303739 , issued by the state of ( FL ) . This identifiers is of the category "MEDICAID".
  • Identifier: 38313 . This is a "MEDICARE PTAN" identifier , issued by the state of ( FL ) . This identifiers is of the category "OTHER".




Copyright © 2007-2024 www.npivalidator.com