Provider Demographics
NPI:1770865917
Name:IRA FIALKO DO PA
Entity Type:Organization
Organization Name:IRA FIALKO DO PA
Other - Org Name:PREMIER PEDIATRICS COASTAL
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:SHAHAB
Authorized Official - Middle Name:
Authorized Official - Last Name:EUNUS
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:352-671-6741
Mailing Address - Street 1:7960 SW 60TH AVE STE 100
Mailing Address - Street 2:
Mailing Address - City:OCALA
Mailing Address - State:FL
Mailing Address - Zip Code:34476-6409
Mailing Address - Country:US
Mailing Address - Phone:352-671-6741
Mailing Address - Fax:352-671-6742
Practice Address - Street 1:6171 W GULF TO LAKE HWY
Practice Address - Street 2:
Practice Address - City:CRYSTAL RIVER
Practice Address - State:FL
Practice Address - Zip Code:34429-2679
Practice Address - Country:US
Practice Address - Phone:352-563-0220
Practice Address - Fax:352-563-0706
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-09-14
Last Update Date:2023-04-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLOS4404208000000X
261QR1300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Single Specialty
No261QR1300XAmbulatory Health Care FacilitiesClinic/CenterRural HealthGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL121610464236OtherHUMANA
GA202840OtherSTAYWELL
FL046778200Medicaid
FL82630OtherBCBS OF FLORIDA
FL267066600OtherFLORIDA MEDICAID GROUP #
FL01118033OtherAMERIGROUP
FL202840OtherHEALTHEASE
FL366272OtherMEDICARE
FL046778200Medicaid