Provider Demographics
NPI:1205928587
Name:PEDIATRIX MEDICAL GROUP PC
Entity type:Organization
Organization Name:PEDIATRIX MEDICAL GROUP PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ASSISTANT SECRETARY
Authorized Official - Prefix:
Authorized Official - First Name:NICHOLAS
Authorized Official - Middle Name:E
Authorized Official - Last Name:GLASER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:954-384-0175
Mailing Address - Street 1:PO BOX 100445
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30384-0445
Mailing Address - Country:US
Mailing Address - Phone:954-384-0175
Mailing Address - Fax:
Practice Address - Street 1:1840 AMHERST ST FL 1
Practice Address - Street 2:
Practice Address - City:WINCHESTER
Practice Address - State:VA
Practice Address - Zip Code:22601-2808
Practice Address - Country:US
Practice Address - Phone:954-384-0175
Practice Address - Fax:954-851-1948
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-28
Last Update Date:2024-11-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2080N0001XAllopathic & Osteopathic PhysiciansPediatricsNeonatal-Perinatal MedicineGroup - Multi-Specialty
No208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA1205928587Medicaid