Provider Demographics
NPI:1821301896
Name:PEDIATRIC ASSOCIATES OF SOUTH FLORIDA LLC
Entity Type:Organization
Organization Name:PEDIATRIC ASSOCIATES OF SOUTH FLORIDA LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:MR
Authorized Official - First Name:GERALD
Authorized Official - Middle Name:D
Authorized Official - Last Name:JONES
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:305-245-3220
Mailing Address - Street 1:151 NW 11TH ST
Mailing Address - Street 2:SUITE E202
Mailing Address - City:HOMESTEAD
Mailing Address - State:FL
Mailing Address - Zip Code:33030-4360
Mailing Address - Country:US
Mailing Address - Phone:305-245-3220
Mailing Address - Fax:
Practice Address - Street 1:151 NW 11TH ST
Practice Address - Street 2:SUITE E202
Practice Address - City:HOMESTEAD
Practice Address - State:FL
Practice Address - Zip Code:33030-4360
Practice Address - Country:US
Practice Address - Phone:305-245-3220
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-07-20
Last Update Date:2012-09-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL002673000Medicaid
FL1821301896Medicaid