Provider Demographics
NPI:1598431884
Name:PEDIATRIC SPECIALTY GROUP, INC.
Entity Type:Organization
Organization Name:PEDIATRIC SPECIALTY GROUP, INC.
Other - Org Name:NICKLAUS CHILDREN'S PEDIATRIC SPECIALISTS - ANESTHESIA
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PROVIDER RELATIONS SPECIALIST
Authorized Official - Prefix:
Authorized Official - First Name:LAURA
Authorized Official - Middle Name:M
Authorized Official - Last Name:GABER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:786-624-5747
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:305-666-6511
Mailing Address - Fax:305-662-8291
Practice Address - Street 1:3100 SW 62ND AVE
Practice Address - Street 2:
Practice Address - City:MIAMI
Practice Address - State:FL
Practice Address - Zip Code:33155-3009
Practice Address - Country:US
Practice Address - Phone:305-666-6511
Practice Address - Fax:305-662-8291
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:PEDIATRIC SPECIALTY GROUP, INC.
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2021-08-18
Last Update Date:2022-10-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiologyGroup - Multi-Specialty
No207LP3000XAllopathic & Osteopathic PhysiciansAnesthesiologyPediatric AnesthesiologyGroup - Multi-Specialty
No367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified RegisteredGroup - Multi-Specialty
No367H00000XPhysician Assistants & Advanced Practice Nursing ProvidersAnesthesiologist AssistantGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL013515238Medicaid