Provider Demographics
NPI:1770606956
Name:PEDIATRIC NEUROLOGY OF SW FL, PA
Entity type:Organization
Organization Name:PEDIATRIC NEUROLOGY OF SW FL, PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:MARGIE
Authorized Official - Middle Name:
Authorized Official - Last Name:MORALES
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:239-433-9383
Mailing Address - Street 1:15880 SUMMERLIN RD
Mailing Address - Street 2:SUITE 300 PMB 178
Mailing Address - City:FORT MYERS
Mailing Address - State:FL
Mailing Address - Zip Code:33908-9612
Mailing Address - Country:US
Mailing Address - Phone:239-433-9383
Mailing Address - Fax:239-433-9356
Practice Address - Street 1:15740 NEW HAMPSHIRE CT
Practice Address - Street 2:SUITE B
Practice Address - City:FORT MYERS
Practice Address - State:FL
Practice Address - Zip Code:33908-4173
Practice Address - Country:US
Practice Address - Phone:239-433-9383
Practice Address - Fax:239-433-9356
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-10
Last Update Date:2008-02-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME51721208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLF77902Medicare UPIN