Healthcare Provider Details

I. General information

NPI: 1922362854
Provider Name (Legal Business Name): PSJ PEDIATRICS, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/26/2012
Last Update Date: 01/13/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3765 KINGS HWY
COCOA FL
32927-5152
US

IV. Provider business mailing address

3765 KINGS HWY
COCOA FL
32927-5152
US

V. Phone/Fax

Practice location:
  • Phone: 321-507-4572
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberME101579
License Number StateFL

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

# 1
Identifier006612100
Identifier TypeMEDICAID
Identifier StateFL
Identifier IssuerFlorida Medicaid Provider ID

VIII. Authorized Official

Name: DR. TARUN JAIN
Title or Position: PRESIDENT
Credential: M.D.
Phone: 321-507-4572