Provider Demographics
NPI:1376617043
Name:BLOOMINGDALE PEDIATRIC ASS PA
Entity Type:Organization
Organization Name:BLOOMINGDALE PEDIATRIC ASS PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PEDIATRICIAN
Authorized Official - Prefix:
Authorized Official - First Name:SONIA
Authorized Official - Middle Name:M
Authorized Official - Last Name:RUIZ
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:813-684-1881
Mailing Address - Street 1:4316 BELL SHOALS RD
Mailing Address - Street 2:
Mailing Address - City:VALRICO
Mailing Address - State:FL
Mailing Address - Zip Code:33594
Mailing Address - Country:US
Mailing Address - Phone:813-684-1881
Mailing Address - Fax:813-685-0471
Practice Address - Street 1:4316 BELL SHOALS RD
Practice Address - Street 2:
Practice Address - City:VALRICO
Practice Address - State:FL
Practice Address - Zip Code:33594
Practice Address - Country:US
Practice Address - Phone:813-684-1881
Practice Address - Fax:813-685-0471
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-17
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME45712208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
00559OtherSTAYWELL
00559OtherHEAHCASE
62614OtherBCBS
26208721OtherAETNA
208721OtherAMERIGROUP
D57517Medicare UPIN