Provider Demographics
NPI:1003217183
Name:PEDIATRICS AT RIVER'S EDGE, INC
Entity Type:Organization
Organization Name:PEDIATRICS AT RIVER'S EDGE, INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:ALDO
Authorized Official - Middle Name:C
Authorized Official - Last Name:DONDERO
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:727-844-3551
Mailing Address - Street 1:6352 RIVER RD
Mailing Address - Street 2:
Mailing Address - City:NEW PORT RICHEY
Mailing Address - State:FL
Mailing Address - Zip Code:34652-2241
Mailing Address - Country:US
Mailing Address - Phone:727-844-3551
Mailing Address - Fax:727-847-0427
Practice Address - Street 1:6352 RIVER RD
Practice Address - Street 2:
Practice Address - City:NEW PORT RICHEY
Practice Address - State:FL
Practice Address - Zip Code:34652-2241
Practice Address - Country:US
Practice Address - Phone:727-844-3551
Practice Address - Fax:727-847-0427
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-09-09
Last Update Date:2017-11-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
208000000X
FL3078370363LP0200X
FL1881067460363LP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Single Specialty
No363LP0200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPediatricsGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL268389000Medicaid