Healthcare Provider Details

I. General information

NPI: 1730486762
Provider Name (Legal Business Name): PEDIATRIC HEALTH CARE ALLIANCE, PA
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/28/2011
Last Update Date: 08/10/2022
Certification Date: 08/10/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5621 SKYTOP DR
LITHIA FL
33547-4165
US

IV. Provider business mailing address

720 BROOKER CREEK BLVD STE 215
OLDSMAR FL
34677-2937
US

V. Phone/Fax

Practice location:
  • Phone: 813-571-6800
  • Fax: 813-654-9939
Mailing address:
  • Phone: 813-854-2003
  • Fax: 813-436-5378

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberME70581
License Number StateFL

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name: DEBRA S GONZALEZ
Title or Position: COO
Credential:
Phone: 813-854-2003