Healthcare Provider Details

I. General information

NPI: 1528160306
Provider Name (Legal Business Name): WEST HIALEAH PEDIATRIC ASSOCIATES, PA
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/02/2006
Last Update Date: 11/06/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

344 W 65TH ST SUITE 201
HIALEAH FL
33012-6719
US

IV. Provider business mailing address

344 W 65TH ST SUITE 201
HIALEAH FL
33012-6719
US

V. Phone/Fax

Practice location:
  • Phone: 305-558-3930
  • Fax: 305-558-3931
Mailing address:
  • Phone: 305-558-3930
  • Fax: 305-558-3931

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberME0065418
License Number StateFL

VIII. Authorized Official

Name: DR. EDUARDO FAUSTO BOLUMEN
Title or Position: PRESIDENT
Credential: M.D.
Phone: 305-558-3930