Provider Demographics
NPI:1396962734
Name:FLORIDA PEDIATRIC GROUP PA
Entity type:Organization
Organization Name:FLORIDA PEDIATRIC GROUP PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:BILLING DEPARTMENT
Authorized Official - Prefix:
Authorized Official - First Name:DEE DEE
Authorized Official - Middle Name:
Authorized Official - Last Name:SCHULTZ
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:321-752-5210
Mailing Address - Street 1:250 S WICKHAM RD
Mailing Address - Street 2:
Mailing Address - City:W MELBOURNE
Mailing Address - State:FL
Mailing Address - Zip Code:32904-1134
Mailing Address - Country:US
Mailing Address - Phone:321-752-5210
Mailing Address - Fax:321-752-5388
Practice Address - Street 1:250 S WICKHAM RD
Practice Address - Street 2:
Practice Address - City:W MELBOURNE
Practice Address - State:FL
Practice Address - Zip Code:32904-1134
Practice Address - Country:US
Practice Address - Phone:321-752-5210
Practice Address - Fax:321-752-5388
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-19
Last Update Date:2025-02-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME81059208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL259807800Medicaid
FL259807800Medicaid