Provider Demographics
NPI:1538651120
Name:ADVANCED KIDS URGENT CARE PROFESSIONALS LLC
Entity Type:Organization
Organization Name:ADVANCED KIDS URGENT CARE PROFESSIONALS LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:BERNADETTE
Authorized Official - Middle Name:
Authorized Official - Last Name:ANTONYRAJAH
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:419-819-7137
Mailing Address - Street 1:98 TERRA MANGO LOOP STE 12
Mailing Address - Street 2:
Mailing Address - City:ORLANDO
Mailing Address - State:FL
Mailing Address - Zip Code:32835-8515
Mailing Address - Country:US
Mailing Address - Phone:407-612-4007
Mailing Address - Fax:407-612-4017
Practice Address - Street 1:98 TERRA MANGO LOOP
Practice Address - Street 2:12
Practice Address - City:ORLANDO
Practice Address - State:FL
Practice Address - Zip Code:32835-8515
Practice Address - Country:US
Practice Address - Phone:407-612-4007
Practice Address - Fax:407-612-4017
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-05-31
Last Update Date:2018-10-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL113681208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL3108461Medicaid