Provider Demographics
NPI:1528003365
Name:THE PEDIATRIC CENTER
Entity Type:Organization
Organization Name:THE PEDIATRIC CENTER
Other - Org Name:THE PEDIATRIC CENTER
Other - Org Type:Other Name
Authorized Official - Title/Position:SEC-TREASURY
Authorized Official - Prefix:
Authorized Official - First Name:ALI
Authorized Official - Middle Name:I
Authorized Official - Last Name:KHOSRAVANI
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:561-790-2600
Mailing Address - Street 1:1447 MEDICAL PARK BLVD
Mailing Address - Street 2:SUITE 402
Mailing Address - City:WELLINGTON
Mailing Address - State:FL
Mailing Address - Zip Code:33414
Mailing Address - Country:US
Mailing Address - Phone:561-790-2600
Mailing Address - Fax:561-790-1535
Practice Address - Street 1:1447 MEDICAL PARK BLVD.
Practice Address - Street 2:SUITE 402
Practice Address - City:WELLINGTON
Practice Address - State:FL
Practice Address - Zip Code:33414
Practice Address - Country:US
Practice Address - Phone:561-790-2600
Practice Address - Fax:561-798-2857
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-17
Last Update Date:2015-12-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL205500OtherAMERIGROUP
FL176316OtherHEALTHEASE
FL378772901Medicaid
FL378772900Medicaid