Healthcare Provider Details

I. General information

NPI: 1699352153
Provider Name (Legal Business Name): KIDS HEART PEDIATRICS PA
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/29/2021
Last Update Date: 03/29/2021
Certification Date: 03/29/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

12505 ORANGE DR STE 907
DAVIE FL
33330-4300
US

IV. Provider business mailing address

12505 ORANGE DR STE 907
DAVIE FL
33330-4300
US

V. Phone/Fax

Practice location:
  • Phone: 954-579-3916
  • Fax: 954-688-7055
Mailing address:
  • Phone: 954-579-3916
  • Fax: 954-688-7055

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2080P0202X
TaxonomyPediatric Cardiology Physician
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number
License Number State

VIII. Authorized Official

Name: MARIA C SERRANO
Title or Position: PD
Credential: MD
Phone: 954-510-2060