Provider Demographics
NPI:1205877719
Name:PLANTATION PEDIATRIC NEUROSURGERY LLC
Entity type:Organization
Organization Name:PLANTATION PEDIATRIC NEUROSURGERY LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:VP
Authorized Official - Prefix:
Authorized Official - First Name:CRAIG
Authorized Official - Middle Name:
Authorized Official - Last Name:WALKER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:954-475-9244
Mailing Address - Street 1:350 NW 84TH AVE
Mailing Address - Street 2:SUITE 108
Mailing Address - City:PLANTATION
Mailing Address - State:FL
Mailing Address - Zip Code:33324-1817
Mailing Address - Country:US
Mailing Address - Phone:954-475-9244
Mailing Address - Fax:
Practice Address - Street 1:350 NW 84TH AVE
Practice Address - Street 2:SUITE 108
Practice Address - City:PLANTATION
Practice Address - State:FL
Practice Address - Zip Code:33324-1817
Practice Address - Country:US
Practice Address - Phone:954-475-9244
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-08
Last Update Date:2008-04-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2086S0120XAllopathic & Osteopathic PhysiciansSurgeryPediatric SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL94737OtherBCBS OF FL
FL=========OtherTRICARE
FLK7185Medicare ID - Type Unspecified