Provider Demographics
NPI:1659778231
Name:ST MARY'S PEDIATRIC CARE PLLC
Entity Type:Organization
Organization Name:ST MARY'S PEDIATRIC CARE PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:EID
Authorized Official - Middle Name:
Authorized Official - Last Name:GUIRGUIS
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:727-754-1984
Mailing Address - Street 1:2626 TAMPA RD
Mailing Address - Street 2:SUITE 101
Mailing Address - City:PALM HARBOR
Mailing Address - State:FL
Mailing Address - Zip Code:34684-3155
Mailing Address - Country:US
Mailing Address - Phone:727-754-1984
Mailing Address - Fax:727-754-2868
Practice Address - Street 1:2626 TAMPA RD
Practice Address - Street 2:SUITE 101
Practice Address - City:PALM HARBOR
Practice Address - State:FL
Practice Address - Zip Code:34684-3155
Practice Address - Country:US
Practice Address - Phone:727-754-1984
Practice Address - Fax:727-754-2868
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-11-26
Last Update Date:2014-11-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME105372208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL0015657Medicaid