Provider Demographics
NPI:1952538720
Name:ANITHA JAGADISH M.D, PA
Entity Type:Organization
Organization Name:ANITHA JAGADISH M.D, PA
Other - Org Name:TENDER CARE PEDIATRICS
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:ANITHA
Authorized Official - Middle Name:
Authorized Official - Last Name:JAGADISH
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:772-335-1812
Mailing Address - Street 1:2115 SE LENNARD RD
Mailing Address - Street 2:
Mailing Address - City:PORT SAINT LUCIE
Mailing Address - State:FL
Mailing Address - Zip Code:34952-4742
Mailing Address - Country:US
Mailing Address - Phone:772-335-1812
Mailing Address - Fax:772-335-1825
Practice Address - Street 1:2115 SE LENNARD RD
Practice Address - Street 2:
Practice Address - City:PORT SAINT LUCIE
Practice Address - State:FL
Practice Address - Zip Code:34952-4742
Practice Address - Country:US
Practice Address - Phone:772-335-1812
Practice Address - Fax:772-335-1825
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-06-18
Last Update Date:2011-10-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME80942208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL260740900Medicaid
FL001280300Medicaid