Provider Demographics
NPI: | 1003306093 |
---|---|
Name: | PEDIATRIC SPECIALTY GROUP, INC |
Entity Type: | Organization |
Organization Name: | PEDIATRIC SPECIALTY GROUP, INC |
Other - Org Name: | NICKLAUS CHILDREN'S COCONUT CREEK CARE CENTER |
Other - Org Type: | Doing Business As |
Authorized Official - Title/Position: | SR. PROVIDER RELATIONS SPECIALIST |
Authorized Official - Prefix: | |
Authorized Official - First Name: | RAIZA |
Authorized Official - Middle Name: | BEATRIZ |
Authorized Official - Last Name: | VIDAURRAZAGA |
Authorized Official - Suffix: | |
Authorized Official - Credentials: | |
Authorized Official - Phone: | 786-624-2186 |
Mailing Address - Street 1: | 3100 SW 62ND AVE |
Mailing Address - Street 2: | |
Mailing Address - City: | MIAMI |
Mailing Address - State: | FL |
Mailing Address - Zip Code: | 33155-3009 |
Mailing Address - Country: | US |
Mailing Address - Phone: | 786-624-5876 |
Mailing Address - Fax: | 786-624-2688 |
Practice Address - Street 1: | 6370 N STATE ROAD 7 STE 100 |
Practice Address - Street 2: | |
Practice Address - City: | COCONUT CREEK |
Practice Address - State: | FL |
Practice Address - Zip Code: | 33073 |
Practice Address - Country: | US |
Practice Address - Phone: | 954-321-7762 |
Practice Address - Fax: | 954-321-9596 |
EIN: | <UNAVAIL> |
Is Organization Subpart?: | No |
Parent Organization LBN: | |
Parent Organization TIN: | |
Enumeration Date: | 2018-05-15 |
Last Update Date: | 2018-09-26 |
Deactivation Date: | |
Deactivation Code: | |
Reactivation Date: |
Provider Taxonomies
Primary? | Code | Type | Classification | Specialization | Group |
---|---|---|---|---|---|
Yes | 207XP3100X | Allopathic & Osteopathic Physicians | Orthopaedic Surgery | Pediatric Orthopaedic Surgery | Group - Multi-Specialty |
No | 207T00000X | Allopathic & Osteopathic Physicians | Neurological Surgery | Group - Multi-Specialty | |
No | 208000000X | Allopathic & Osteopathic Physicians | Pediatrics | Group - Multi-Specialty | |
No | 2080P0201X | Allopathic & Osteopathic Physicians | Pediatrics | Pediatric Allergy/Immunology | Group - Multi-Specialty |
No | 2080P0202X | Allopathic & Osteopathic Physicians | Pediatrics | Pediatric Cardiology | Group - Multi-Specialty |
No | 2080P0204X | Allopathic & Osteopathic Physicians | Pediatrics | Pediatric Emergency Medicine | Group - Multi-Specialty |
No | 2080P0205X | Allopathic & Osteopathic Physicians | Pediatrics | Pediatric Endocrinology | Group - Multi-Specialty |
No | 2080P0206X | Allopathic & Osteopathic Physicians | Pediatrics | Pediatric Gastroenterology | Group - Multi-Specialty |
No | 2080P0210X | Allopathic & Osteopathic Physicians | Pediatrics | Pediatric Nephrology | Group - Multi-Specialty |
No | 2080P0216X | Allopathic & Osteopathic Physicians | Pediatrics | Pediatric Rheumatology | Group - Multi-Specialty |
No | 208200000X | Allopathic & Osteopathic Physicians | Plastic Surgery | Group - Multi-Specialty | |
No | 2085P0229X | Allopathic & Osteopathic Physicians | Radiology | Pediatric Radiology | Group - Multi-Specialty |
No | 261QR0400X | Ambulatory Health Care Facilities | Clinic/Center | Rehabilitation | |
No | 261QU0200X | Ambulatory Health Care Facilities | Clinic/Center | Urgent Care | |
No | 282NC2000X | Hospitals | General Acute Care Hospital | Children | Group - Multi-Specialty |
Provider Identifiers
State | Identifier ID | ID Type | Issuer |
---|---|---|---|
FL | 010060900 | Medicaid |