Provider Demographics
NPI:1033194816
Name:PEDIATRIC SURGICAL GROUP, P.A.
Entity Type:Organization
Organization Name:PEDIATRIC SURGICAL GROUP, P.A.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRACTICE MANAGER
Authorized Official - Prefix:MRS
Authorized Official - First Name:CATHY
Authorized Official - Middle Name:
Authorized Official - Last Name:CLARK
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:727-767-3221
Mailing Address - Street 1:880 6TH ST S
Mailing Address - Street 2:SUITE 210
Mailing Address - City:ST PETERSBURG
Mailing Address - State:FL
Mailing Address - Zip Code:33701-4827
Mailing Address - Country:US
Mailing Address - Phone:727-767-4170
Mailing Address - Fax:727-767-4346
Practice Address - Street 1:880 6TH ST S
Practice Address - Street 2:SUITE 210
Practice Address - City:ST PETERSBURG
Practice Address - State:FL
Practice Address - Zip Code:33701-4827
Practice Address - Country:US
Practice Address - Phone:727-767-4170
Practice Address - Fax:727-767-4346
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-12-14
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME00552902086S0120X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2086S0120XAllopathic & Osteopathic PhysiciansSurgeryPediatric SurgeryGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL00219Medicare ID - Type Unspecified