Healthcare Provider Details

I. General information

NPI: 1245855063
Provider Name (Legal Business Name): PEDIATRIC ASSOCIATES OF TAMPA BAY, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/09/2020
Last Update Date: 06/09/2020
Certification Date: 06/09/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

901 E BLOOMINGDALE AVE # 501
BRANDON FL
33511-8118
US

IV. Provider business mailing address

900 S PINE ISLAND RD STE 800
PLANTATION FL
33324-3923
US

V. Phone/Fax

Practice location:
  • Phone: 941-909-7003
  • Fax: 941-209-6386
Mailing address:
  • Phone: 954-967-6400
  • Fax: 954-965-7339

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number
License Number State

VIII. Authorized Official

Name: PATRICIA CORSIATTO
Title or Position: DIRECTOR CREDENTIALING
Credential:
Phone: 954-965-7331