Provider Demographics
NPI:1053315572
Name:MEDPEDS ASSOCIATES OF SARASOTA
Entity Type:Organization
Organization Name:MEDPEDS ASSOCIATES OF SARASOTA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRACTICE ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:LISA
Authorized Official - Middle Name:
Authorized Official - Last Name:DEMENT
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:941-955-8800
Mailing Address - Street 1:1931 S TUTTLE AVE
Mailing Address - Street 2:
Mailing Address - City:SARASOTA
Mailing Address - State:FL
Mailing Address - Zip Code:34239-3115
Mailing Address - Country:US
Mailing Address - Phone:941-955-8800
Mailing Address - Fax:941-955-8842
Practice Address - Street 1:1931 S TUTTLE AVE
Practice Address - Street 2:
Practice Address - City:SARASOTA
Practice Address - State:FL
Practice Address - Zip Code:34239-3115
Practice Address - Country:US
Practice Address - Phone:941-955-8800
Practice Address - Fax:941-955-8842
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-06-13
Last Update Date:2023-09-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLOS8062207R00000X, 208000000X
207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty
No208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL258916800Medicaid
FL258916800Medicaid