Provider Demographics
NPI:1073046397
Name:ADVANCED PEDIATRIC SPECIALISTS LLC
Entity Type:Organization
Organization Name:ADVANCED PEDIATRIC SPECIALISTS LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:MARK
Authorized Official - Middle Name:
Authorized Official - Last Name:COFFEY
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:912-295-2133
Mailing Address - Street 1:PO BOX 12189
Mailing Address - Street 2:
Mailing Address - City:DAYTONA BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:32120-2189
Mailing Address - Country:US
Mailing Address - Phone:386-274-7800
Mailing Address - Fax:386-274-7801
Practice Address - Street 1:5353 REYNOLDS ST
Practice Address - Street 2:
Practice Address - City:SAVANNAH
Practice Address - State:GA
Practice Address - Zip Code:31405-6015
Practice Address - Country:US
Practice Address - Phone:912-819-6000
Practice Address - Fax:386-274-7801
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-04-04
Last Update Date:2017-04-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Multi-Specialty