Provider Demographics
NPI:1598229890
Name:PEDIATRIC SPECIALTY GROUP, INC
Entity Type:Organization
Organization Name:PEDIATRIC SPECIALTY GROUP, INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:SR. PROVIDER RELATIONS SPECIALIST
Authorized Official - Prefix:
Authorized Official - First Name:RAIZA
Authorized Official - Middle Name:BEATRIZ
Authorized Official - Last Name:VIDAURRAZAGA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:786-624-2186
Mailing Address - Street 1:3100 SW 62ND AVE
Mailing Address - Street 2:
Mailing Address - City:MIAMI
Mailing Address - State:FL
Mailing Address - Zip Code:33155-3009
Mailing Address - Country:US
Mailing Address - Phone:772-286-8133
Mailing Address - Fax:
Practice Address - Street 1:3228 SW MARTIN DOWNS BLVD
Practice Address - Street 2:
Practice Address - City:PALM CITY
Practice Address - State:FL
Practice Address - Zip Code:34990-2679
Practice Address - Country:US
Practice Address - Phone:772-286-8133
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:PEDIATRIC SPECIALTY GROUP, INC.
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2019-01-31
Last Update Date:2019-01-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Multi-Specialty
No2080I0007XAllopathic & Osteopathic PhysiciansPediatricsClinical & Laboratory ImmunologyGroup - Multi-Specialty
No2080P0202XAllopathic & Osteopathic PhysiciansPediatricsPediatric CardiologyGroup - Multi-Specialty
No2080P0205XAllopathic & Osteopathic PhysiciansPediatricsPediatric EndocrinologyGroup - Multi-Specialty
No2080P0206XAllopathic & Osteopathic PhysiciansPediatricsPediatric GastroenterologyGroup - Multi-Specialty