Healthcare Provider Details

I. General information

NPI: 1780615047
Provider Name (Legal Business Name): PEDIATRIC SERVICES OF AMERICA, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/05/2006
Last Update Date: 01/27/2025
Certification Date: 01/27/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8659 BAYPINE RD STE 102
JACKSONVILLE FL
32256-7577
US

IV. Provider business mailing address

400 INTERSTATE NORTH PKWY SE STE 1600
ATLANTA GA
30339-5047
US

V. Phone/Fax

Practice location:
  • Phone: 904-730-2200
  • Fax: 904-730-0630
Mailing address:
  • Phone: 470-464-8000
  • Fax: 770-248-8192

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code251J00000X
TaxonomyNursing Care Agency
License NumberHHA 20798096
License Number StateFL

VIII. Authorized Official

Name: MATTHEW BUCKHALTER
Title or Position: CFO
Credential:
Phone: 470-464-8000