1639538713 NPI number — PENINSULA PEDIATRICS OF WEST FLORIDA, PLLC

Table of content: (NPI 1639538713)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1639538713 NPI number — PENINSULA PEDIATRICS OF WEST FLORIDA, PLLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
PENINSULA PEDIATRICS OF WEST FLORIDA, PLLC
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:
1639538713
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
06/05/2023
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
13163 66TH STREET
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
LARGO
Provider Business Mailing Address State Name:
FL
Provider Business Mailing Address Postal Code:
33773
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
727-228-7000
Provider Business Mailing Address Fax Number:
727-223-3614

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
13163 66TH STREET
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
LARGO
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
33773
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
727-228-7000
Provider Business Practice Location Address Fax Number:
727-223-3614
Provider Enumeration Date:
02/17/2016

Additional Information

Authorized Official

Authorized Official Last Name:
MOORE
Authorized Official First Name:
STEVEN
Authorized Official Middle Name:
MICHAEL
Authorized Official Title or Position:
OWNER
Authorized Official Telephone Number:
727-228-7000

Provider Taxonomy Codes

  • Taxonomy code: 208000000X , with the licence number:  ME 100692 , 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: 018367100 , issued by the state of ( FL ) . This identifiers is of the category "MEDICAID".




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