1447553805 NPI number — FLORIDA PEDIATRIC ASSOCIATES, LLC

Table of content: (NPI 1447553805)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1447553805 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:
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:
1447553805
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:
1781 PARK CENTER DR
Provider Second Line Business Practice Location Address:
SUITE 220
Provider Business Practice Location Address City Name:
ORLANDO
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
32835-6254
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
407-398-7730
Provider Business Practice Location Address Fax Number:
407-398-7740
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: 38313 . This is a "MEDICARE PTAN" identifier , issued by the state of ( FL ) . This identifiers is of the category "OTHER".




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