1336539303 NPI number — EZ-PEDIATRICS

Table of content: (NPI 1336539303)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1336539303 NPI number — EZ-PEDIATRICS

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
EZ-PEDIATRICS
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:
6
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:
1336539303
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
10/20/2016
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
10794 PINES BLVD
Provider Second Line Business Mailing Address:
STE 102
Provider Business Mailing Address City Name:
PEMBROKE PINES
Provider Business Mailing Address State Name:
FL
Provider Business Mailing Address Postal Code:
33026-3920
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
954-431-8558
Provider Business Mailing Address Fax Number:
954-431-3867

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
10794 PINES BLVD
Provider Second Line Business Practice Location Address:
STE 102
Provider Business Practice Location Address City Name:
PEMBROKE PINES
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
33026-3920
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
954-431-8558
Provider Business Practice Location Address Fax Number:
954-431-3867
Provider Enumeration Date:
01/29/2015

Additional Information

Authorized Official

Authorized Official Last Name:
ZAMBRANO
Authorized Official First Name:
MARIO
Authorized Official Middle Name:
DONALD
Authorized Official Title or Position:
ATTENDING PHYSICIAN/CEO
Authorized Official Telephone Number:
954-431-8558

Provider Taxonomy Codes

  • Taxonomy code: 261Q00000X , with the licence number:  ME068860 , 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: G151181 . This is a "UPIN" identifier , issued by the state of ( FL ) . This identifiers is of the category "OTHER".
  • Identifier: 1750832366 . This is a "NPI" identifier , issued by the state of ( FL ) . This identifiers is of the category "OTHER".
  • Identifier: 1336539303 . This is a "GROUP NPI" identifier , issued by the state of ( FL ) . This identifiers is of the category "OTHER".
  • Identifier: 1508815531 . This is a "NPI" identifier , issued by the state of ( FL ) . This identifiers is of the category "OTHER".
  • Identifier: 378700100 , issued by the state of ( FL ) . This identifiers is of the category "MEDICAID".
  • Identifier: 017221800 . 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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