Provider Demographics
NPI:1023039351
Name:PEDIATRIC SURGERY P.A.
Entity Type:Organization
Organization Name:PEDIATRIC SURGERY P.A.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:MARK
Authorized Official - Middle Name:S
Authorized Official - Last Name:CHAET
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:407-228-4774
Mailing Address - Street 1:1220 SLIGH BLVD
Mailing Address - Street 2:
Mailing Address - City:ORLANDO
Mailing Address - State:FL
Mailing Address - Zip Code:32806-1108
Mailing Address - Country:US
Mailing Address - Phone:407-228-4774
Mailing Address - Fax:407-228-2128
Practice Address - Street 1:1220 SLIGH BLVD
Practice Address - Street 2:
Practice Address - City:ORLANDO
Practice Address - State:FL
Practice Address - Zip Code:32806-1108
Practice Address - Country:US
Practice Address - Phone:407-228-4774
Practice Address - Fax:407-228-2128
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-21
Last Update Date:2015-11-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2086S0120XAllopathic & Osteopathic PhysiciansSurgeryPediatric SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL253269700Medicaid