Provider Demographics
NPI:1518911569
Name:FUNCOAST PEDIATRICS PA
Entity Type:Organization
Organization Name:FUNCOAST PEDIATRICS PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:JAMES
Authorized Official - Middle Name:GRADY
Authorized Official - Last Name:WHITE
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:386-677-3530
Mailing Address - Street 1:1688 W GRANADA BLVD
Mailing Address - Street 2:SUITE 2B
Mailing Address - City:ORMOND BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:32174
Mailing Address - Country:US
Mailing Address - Phone:386-677-3530
Mailing Address - Fax:386-673-1933
Practice Address - Street 1:1688 W GRANADA BLVD
Practice Address - Street 2:SUITE 2B
Practice Address - City:ORMOND BEACH
Practice Address - State:FL
Practice Address - Zip Code:32174
Practice Address - Country:US
Practice Address - Phone:386-677-3530
Practice Address - Fax:386-673-1933
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-22
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Single Specialty