Healthcare Provider Details

I. General information

NPI: 1659638849
Provider Name (Legal Business Name): PEDIATRIC INTENSIVIST GROUP LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/12/2012
Last Update Date: 04/12/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1700 S 23RD ST
FORT PIERCE FL
34950-4803
US

IV. Provider business mailing address

111 JFK DR STE A
ATLANTIS FL
33462-6634
US

V. Phone/Fax

Practice location:
  • Phone: 720-530-9100
  • Fax:
Mailing address:
  • Phone: 954-767-5716
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2080P0203X
TaxonomyPediatric Critical Care Medicine Physician
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number
License Number State

VIII. Authorized Official

Name: WARREN STOWELL
Title or Position: VP PHYSICIAN SERVICES, HCA
Credential:
Phone: 954-767-5716