Provider Demographics
NPI:1275554248
Name:PEDIATRIC PROVIDERS OF S FLORIDA
Entity Type:Organization
Organization Name:PEDIATRIC PROVIDERS OF S FLORIDA
Other - Org Name:JORGE L CABRERA MD
Other - Org Type:Doing Business As
Authorized Official - Title/Position:MANAGED CARE SPEC- ALLSCRIPTS
Authorized Official - Prefix:
Authorized Official - First Name:DIRENDIA
Authorized Official - Middle Name:
Authorized Official - Last Name:SHACKELFORD
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:800-680-0889
Mailing Address - Street 1:464 W 51ST PL
Mailing Address - Street 2:
Mailing Address - City:HIALEAH
Mailing Address - State:FL
Mailing Address - Zip Code:33012-3620
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:464 W 51ST PL
Practice Address - Street 2:
Practice Address - City:HIALEAH
Practice Address - State:FL
Practice Address - Zip Code:33012-3620
Practice Address - Country:US
Practice Address - Phone:305-551-1281
Practice Address - Fax:305-362-9138
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-22
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME49402332900000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332900000XSuppliersNon-Pharmacy Dispensing Site
Provider Identifiers
StateIdentifier IDID TypeIssuer
1017854OtherOTHER ID NUMBER-COMMERCIAL NUMBER