Provider Demographics
NPI:1730486762
Name:PEDIATRIC HEALTH CARE ALLIANCE, PA
Entity Type:Organization
Organization Name:PEDIATRIC HEALTH CARE ALLIANCE, PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:COO
Authorized Official - Prefix:
Authorized Official - First Name:DEBRA
Authorized Official - Middle Name:S
Authorized Official - Last Name:GONZALEZ
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:813-854-2003
Mailing Address - Street 1:720 BROOKER CREEK BLVD STE 215
Mailing Address - Street 2:
Mailing Address - City:OLDSMAR
Mailing Address - State:FL
Mailing Address - Zip Code:34677-2937
Mailing Address - Country:US
Mailing Address - Phone:813-854-2003
Mailing Address - Fax:813-436-5378
Practice Address - Street 1:5621 SKYTOP DR
Practice Address - Street 2:
Practice Address - City:LITHIA
Practice Address - State:FL
Practice Address - Zip Code:33547-4165
Practice Address - Country:US
Practice Address - Phone:813-571-6800
Practice Address - Fax:813-654-9939
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:PEDIATRIC HEALTH CARE ALLIANCE, PA
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2011-02-28
Last Update Date:2022-08-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME70581208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Single Specialty