Provider Demographics
NPI:1720179120
Name:PALM HARBOR PEDIATRIC URGENT CARE CENTER PA
Entity Type:Organization
Organization Name:PALM HARBOR PEDIATRIC URGENT CARE CENTER PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PROVIDER/OWNER
Authorized Official - Prefix:
Authorized Official - First Name:LUIS
Authorized Official - Middle Name:
Authorized Official - Last Name:MARAMARA
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:727-787-5439
Mailing Address - Street 1:PO BOX 23863
Mailing Address - Street 2:
Mailing Address - City:TAMPA
Mailing Address - State:FL
Mailing Address - Zip Code:33623-3863
Mailing Address - Country:US
Mailing Address - Phone:727-823-2188
Mailing Address - Fax:727-823-9502
Practice Address - Street 1:36458 US HIGHWAY 19 N
Practice Address - Street 2:
Practice Address - City:PALM HARBOR
Practice Address - State:FL
Practice Address - Zip Code:34684-1330
Practice Address - Country:US
Practice Address - Phone:727-787-5439
Practice Address - Fax:727-787-6221
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-28
Last Update Date:2008-12-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QU0200XAmbulatory Health Care FacilitiesClinic/CenterUrgent Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
282538OtherAVMED
FLB903QOtherBCBS
FL196501OtherWELLCARE
220597OtherAMERIGROUP
FL271730100Medicaid
282538OtherAVMED