Provider Demographics
NPI:1912345497
Name:PEDIATRIC ASSOCIATES OF TAMPA BAY, LLC
Entity Type:Organization
Organization Name:PEDIATRIC ASSOCIATES OF TAMPA BAY, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:DR
Authorized Official - First Name:PETER
Authorized Official - Middle Name:J
Authorized Official - Last Name:SHULMAN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:954-965-7322
Mailing Address - Street 1:900 S PINE ISLAND RD
Mailing Address - Street 2:800
Mailing Address - City:PLANTATION
Mailing Address - State:FL
Mailing Address - Zip Code:33324-3920
Mailing Address - Country:US
Mailing Address - Phone:954-967-6400
Mailing Address - Fax:954-965-7339
Practice Address - Street 1:10710 STATE ROAD 54 STE 108
Practice Address - Street 2:
Practice Address - City:TRINITY
Practice Address - State:FL
Practice Address - Zip Code:34655-2263
Practice Address - Country:US
Practice Address - Phone:727-376-4040
Practice Address - Fax:727-376-8824
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:PEDIATRIC ASSOCIATES HOLDING COMPANY
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2013-06-06
Last Update Date:2020-08-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL008927601Medicaid