Provider Demographics
NPI:1316589914
Name:PEDIATRIC SPECIALTY GROUP, INC.
Entity Type:Organization
Organization Name:PEDIATRIC SPECIALTY GROUP, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR, MEDICAL STAFF
Authorized Official - Prefix:
Authorized Official - First Name:ELIZABETH
Authorized Official - Middle Name:
Authorized Official - Last Name:MENOCAL
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:305-662-8357
Mailing Address - Street 1:PO BOX 865095
Mailing Address - Street 2:
Mailing Address - City:ORLANDO
Mailing Address - State:FL
Mailing Address - Zip Code:32886-5095
Mailing Address - Country:US
Mailing Address - Phone:954-575-1211
Mailing Address - Fax:954-575-1205
Practice Address - Street 1:9750 NW 33RD ST STE 109
Practice Address - Street 2:
Practice Address - City:CORAL SPRINGS
Practice Address - State:FL
Practice Address - Zip Code:33065-4000
Practice Address - Country:US
Practice Address - Phone:954-575-1211
Practice Address - Fax:954-575-1205
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:PEDIATRIC SPECIALTY GROUP, INC.
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2019-10-15
Last Update Date:2019-10-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2080P0202XAllopathic & Osteopathic PhysiciansPediatricsPediatric CardiologyGroup - Multi-Specialty
No208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Multi-Specialty