Provider Demographics
NPI:1376640078
Name:PEDIATRIX MEDICAL GROUP NEONATOLOGY AND PEDIATRIC INTENSIVE CARE SPECI
Entity Type:Organization
Organization Name:PEDIATRIX MEDICAL GROUP NEONATOLOGY AND PEDIATRIC INTENSIVE CARE SPECI
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:AUTHORIZED SIGNATOR
Authorized Official - Prefix:
Authorized Official - First Name:ARNOLD
Authorized Official - Middle Name:M
Authorized Official - Last Name:POOLE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:954-384-0175
Mailing Address - Street 1:4991 LAKE BROOK DR
Mailing Address - Street 2:SUITE 300
Mailing Address - City:GLEN ALLEN
Mailing Address - State:VA
Mailing Address - Zip Code:23060-9293
Mailing Address - Country:US
Mailing Address - Phone:804-346-3535
Mailing Address - Fax:804-253-0408
Practice Address - Street 1:1301 CONCORD TER
Practice Address - Street 2:
Practice Address - City:SUNRISE
Practice Address - State:FL
Practice Address - Zip Code:33323-2843
Practice Address - Country:US
Practice Address - Phone:954-384-0175
Practice Address - Fax:954-851-1948
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-17
Last Update Date:2010-08-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2080N0001XAllopathic & Osteopathic PhysiciansPediatricsNeonatal-Perinatal MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY3069683Medicaid