1497944193 NPI number — CHILDREN'S SPECIALIST PEDIATRIC PULMONOLOGY OF FLORIDA LLC

Table of content: (NPI 1497944193)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1497944193 NPI number — CHILDREN'S SPECIALIST PEDIATRIC PULMONOLOGY OF FLORIDA LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
CHILDREN'S SPECIALIST PEDIATRIC PULMONOLOGY OF FLORIDA LLC
Provider Last Name:
Provider First Name:
Provider Middle Name:
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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:
Provider Other Last Name:
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NPI Number Information

NPI Number:
1497944193
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
04/17/2023
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
12748 UNIVERSITY DR
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
FORT MYERS
Provider Business Mailing Address State Name:
FL
Provider Business Mailing Address Postal Code:
33907-5634
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
239-437-5500
Provider Business Mailing Address Fax Number:
239-437-5507

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
12748 UNIVERSITY DR
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
FORT MYERS
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
33907-5634
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
239-464-8089
Provider Business Practice Location Address Fax Number:
239-437-5507
Provider Enumeration Date:
10/18/2007

Additional Information

Authorized Official

Authorized Official Last Name:
WEGELIN
Authorized Official First Name:
KATHLEEN
Authorized Official Middle Name:
Authorized Official Title or Position:
OFFICE ADMINISTRATOR
Authorized Official Telephone Number:
239-437-5500

Provider Taxonomy Codes

  • Taxonomy code: 174400000X , with the licence number:  ME0091014 , 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)





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