Provider Demographics
NPI:1477007318
Name:PEDIATRIC SPECIALTY GROUP, INC.
Entity Type:Organization
Organization Name:PEDIATRIC SPECIALTY GROUP, INC.
Other - Org Name:PEDIATRIC SPECIALISTS OF AMERICA- RHEUMATOLOGY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PROVIDER RELATIONS SPECIALIST
Authorized Official - Prefix:
Authorized Official - First Name:LAURA
Authorized Official - Middle Name:M
Authorized Official - Last Name:GABER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:786-624-5747
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:786-624-5876
Mailing Address - Fax:786-624-2688
Practice Address - Street 1:3100 SW 62ND AVE
Practice Address - Street 2:SUITE 105
Practice Address - City:MIAMI
Practice Address - State:FL
Practice Address - Zip Code:33155
Practice Address - Country:US
Practice Address - Phone:786-624-5876
Practice Address - Fax:786-624-2688
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-08-09
Last Update Date:2021-03-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2080P0216XAllopathic & Osteopathic PhysiciansPediatricsPediatric RheumatologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL013515206Medicaid