Provider Demographics
NPI:1346442506
Name:PREMIER CARE PEDIATRICS, PA
Entity Type:Organization
Organization Name:PREMIER CARE PEDIATRICS, PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:MATTHEW
Authorized Official - Middle Name:CAMERON
Authorized Official - Last Name:MINICK
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:813-657-7337
Mailing Address - Street 1:16637 FISHHAWK BLVD
Mailing Address - Street 2:SUITE 101
Mailing Address - City:LITHIA
Mailing Address - State:FL
Mailing Address - Zip Code:33547-3918
Mailing Address - Country:US
Mailing Address - Phone:813-657-7337
Mailing Address - Fax:813-661-4702
Practice Address - Street 1:16637 FISHHAWK BLVD
Practice Address - Street 2:SUITE 101
Practice Address - City:LITHIA
Practice Address - State:FL
Practice Address - Zip Code:33547-3918
Practice Address - Country:US
Practice Address - Phone:813-657-7337
Practice Address - Fax:813-661-4702
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-06-01
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME90457208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Single Specialty