Healthcare Provider Details

I. General information

NPI: 1336328046
Provider Name (Legal Business Name): PEDIATRIC MD SERVICES, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/30/2007
Last Update Date: 09/21/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1325 S CONGRESS AVE SUITE 109
BOYNTON BEACH FL
33426-5876
US

IV. Provider business mailing address

1325 S CONGRESS AVE SUITE 109
BOYNTON BEACH FL
33426-5876
US

V. Phone/Fax

Practice location:
  • Phone: 561-736-2510
  • Fax: 561-503-4873
Mailing address:
  • Phone: 561-736-2510
  • Fax: 561-503-4873

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberME90011
License Number StateFL

VIII. Authorized Official

Name: SUZANNE PAVLOU
Title or Position: PRESIDENT/CEO
Credential: MD
Phone: 561-736-2510