Provider Demographics
NPI:1508002072
Name:PEDIATRIC ENT, LLC
Entity type:Organization
Organization Name:PEDIATRIC ENT, LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:DR
Authorized Official - First Name:DAVID
Authorized Official - Middle Name:JOEL
Authorized Official - Last Name:MALIS
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:321-254-5437
Mailing Address - Street 1:1499 S HARBOR CITY BLVD STE 303
Mailing Address - Street 2:
Mailing Address - City:MELBOURNE
Mailing Address - State:FL
Mailing Address - Zip Code:32901-3245
Mailing Address - Country:US
Mailing Address - Phone:321-254-5437
Mailing Address - Fax:321-254-4543
Practice Address - Street 1:1499 S HARBOR CITY BLVD STE 303
Practice Address - Street 2:
Practice Address - City:MELBOURNE
Practice Address - State:FL
Practice Address - Zip Code:32901-3245
Practice Address - Country:US
Practice Address - Phone:321-254-5437
Practice Address - Fax:321-254-4543
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-01-05
Last Update Date:2014-04-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME90348207YP0228X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207YP0228XAllopathic & Osteopathic PhysiciansOtolaryngologyPediatric OtolaryngologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL01269821OtherMEDICAID HMO - AMERIGROUP
FL2258392OtherMEDICAID HMO - UNITED HEALTH CARE
FL332181OtherMEDICAID HMO - WELLCARE
FL271247400Medicaid