Provider Demographics
NPI:1295757227
Name:PEDIATRIC SERVICES OF AMERICA, LLC
Entity type:Organization
Organization Name:PEDIATRIC SERVICES OF AMERICA, LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CFO
Authorized Official - Prefix:
Authorized Official - First Name:MATTHEW
Authorized Official - Middle Name:
Authorized Official - Last Name:BUCKHALTER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:470-464-8000
Mailing Address - Street 1:400 INTERSTATE NORTH PKWY SE STE 1600
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30339-5047
Mailing Address - Country:US
Mailing Address - Phone:470-464-8000
Mailing Address - Fax:770-248-8192
Practice Address - Street 1:2005 VISTA PKWY
Practice Address - Street 2:SUITE 110 A
Practice Address - City:WEST PALM BEACH
Practice Address - State:FL
Practice Address - Zip Code:33411-2719
Practice Address - Country:US
Practice Address - Phone:561-683-5758
Practice Address - Fax:561-683-3416
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-25
Last Update Date:2025-01-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
261QR0400X
FLPPC6010096261QM3000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM3000XAmbulatory Health Care FacilitiesClinic/CenterMedically Fragile Infants and Children Day Care
No261QR0400XAmbulatory Health Care FacilitiesClinic/CenterRehabilitation
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL884708800Medicaid
FL300198900Medicaid
FL300204700Medicaid