Provider Demographics
NPI:1326380213
Name:PEDIATRIC ASSOCIATES PA
Entity Type:Organization
Organization Name:PEDIATRIC ASSOCIATES PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:SHANNON
Authorized Official - Middle Name:
Authorized Official - Last Name:DYER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:850-478-1104
Mailing Address - Street 1:12385 SORRENTO RD
Mailing Address - Street 2:
Mailing Address - City:PENSACOLA
Mailing Address - State:FL
Mailing Address - Zip Code:32507-8664
Mailing Address - Country:US
Mailing Address - Phone:850-492-0257
Mailing Address - Fax:850-492-8999
Practice Address - Street 1:12385 SORRENTO RD
Practice Address - Street 2:SUITE C4
Practice Address - City:PENSACOLA
Practice Address - State:FL
Practice Address - Zip Code:32507-8664
Practice Address - Country:US
Practice Address - Phone:850-478-1100
Practice Address - Fax:850-478-4289
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:PEDIATRIC ASSOCIATES PA
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2013-03-19
Last Update Date:2013-03-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207K00000XAllopathic & Osteopathic PhysiciansAllergy & ImmunologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL280234102Medicaid