Healthcare Provider Details

I. General information

NPI: 1205193455
Provider Name (Legal Business Name): PEDIATRIC EMERGENCY MEDICINE DEPARTMENT
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

10000 SW 52ND AVE APT 96
GAINESVILLE FL
32608-8335
US

IV. Provider business mailing address

10000 SW 52ND AVE APT 96
GAINESVILLE FL
32608-8335
US

V. Phone/Fax

Practice location:
  • Phone: 813-240-2610
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code282NC2000X
TaxonomyChildren's Hospital
License NumberMD.31618
License Number StateAL

VIII. Authorized Official

Name: ANN KLASNER
Title or Position: DIRECTOR
Credential:
Phone: 205-939-9587