MEDICARE: WEECARE FOR KIDS PA

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	208000000X	Pediatrics Physician	ME82918	FL

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	005NB	OTHER		BLUE CROSS BLUE SHIELD

General Provider Information

NPI Number	:	1144636861
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	WEECARE FOR KIDS PA

Provider Business Mailing Address
First Line	:	11948 BALM RIVERVIEW RD
Second Line	:
City	:	RIVERVIEW
State	:	FL
Zip	:	33569-6601
Country	:	US
Telephone Number	:	813-236-9000
Fax Number	:	813-236-9002

Provider Business Practice Location Address
First Line	:	11948 BALM RIVERVIEW RD
Second Line	:
City	:	RIVERVIEW
State	:	FL
Zip	:	33569-6601
Country	:	US
Telephone Number	:	813-236-9000
Fax Number	:	813-236-9002

Authorized Official
Title or Position	:	OWNER
Name	:	HEATHER SUE THOLE
Credential	:	MD
Telephone Number	:	813-236-9000

Provider Enumeration Date	:	07/02/2014
Last Update Date	:	08/27/2014

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