Provider Demographics
NPI:1477511970
Name:PEDIATRIC HEMATOLOGY/ONCOLOGY ASC PA
Entity Type:Organization
Organization Name:PEDIATRIC HEMATOLOGY/ONCOLOGY ASC PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEDICAL DIRECTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:JERRY
Authorized Official - Middle Name:L
Authorized Official - Last Name:BARBOSA
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:727-767-4231
Mailing Address - Street 1:880 6TH ST S
Mailing Address - Street 2:SUITE 140
Mailing Address - City:ST PETERSBURG
Mailing Address - State:FL
Mailing Address - Zip Code:33701-4827
Mailing Address - Country:US
Mailing Address - Phone:727-767-4231
Mailing Address - Fax:
Practice Address - Street 1:880 6TH ST S
Practice Address - Street 2:SUITE 140
Practice Address - City:ST PETERSBURG
Practice Address - State:FL
Practice Address - Zip Code:33701-4827
Practice Address - Country:US
Practice Address - Phone:727-767-4231
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-03
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2080P0207XAllopathic & Osteopathic PhysiciansPediatricsPediatric Hematology-OncologyGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL59684OtherAETNA
FL24216OtherBCBS
FL59684OtherAETNA