Provider Demographics
NPI:1811026354
Name:PEDIATRIC MEDICINE ASSOCIATES GROUP INC.
Entity Type:Organization
Organization Name:PEDIATRIC MEDICINE ASSOCIATES GROUP INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MD
Authorized Official - Prefix:
Authorized Official - First Name:JORGE
Authorized Official - Middle Name:A
Authorized Official - Last Name:DE DIEGO
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:305-477-7111
Mailing Address - Street 1:10820 NW 58TH ST
Mailing Address - Street 2:
Mailing Address - City:DORAL
Mailing Address - State:FL
Mailing Address - Zip Code:33178-2854
Mailing Address - Country:US
Mailing Address - Phone:305-477-7111
Mailing Address - Fax:305-594-3126
Practice Address - Street 1:10820 NW 58TH ST
Practice Address - Street 2:
Practice Address - City:DORAL
Practice Address - State:FL
Practice Address - Zip Code:33178-2854
Practice Address - Country:US
Practice Address - Phone:305-477-7111
Practice Address - Fax:305-594-3126
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-02
Last Update Date:2022-11-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME48450208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL106861000Medicaid
FL1811026354Medicaid