Provider Demographics
NPI:1578860078
Name:PERSONAL PEDIATRIC CARE PLLC
Entity Type:Organization
Organization Name:PERSONAL PEDIATRIC CARE PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICIAN
Authorized Official - Prefix:
Authorized Official - First Name:JAY
Authorized Official - Middle Name:MICHAEL
Authorized Official - Last Name:HARVEY
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:727-645-6941
Mailing Address - Street 1:3012 STARKEY BLVD
Mailing Address - Street 2:
Mailing Address - City:TRINITY
Mailing Address - State:FL
Mailing Address - Zip Code:34655-2175
Mailing Address - Country:US
Mailing Address - Phone:727-645-6941
Mailing Address - Fax:727-494-7684
Practice Address - Street 1:3012 STARKEY BLVD
Practice Address - Street 2:
Practice Address - City:TRINITY
Practice Address - State:FL
Practice Address - Zip Code:34655-2175
Practice Address - Country:US
Practice Address - Phone:727-645-6941
Practice Address - Fax:727-494-7684
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-02-17
Last Update Date:2011-02-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME58972208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL054287300Medicaid