Healthcare Provider Details

I. General information

NPI: 1376846733
Provider Name (Legal Business Name): FLORIDA PEDIATRIC ASSOCIATES, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/07/2010
Last Update Date: 12/07/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

790 CONCOURSE PKWY S SUITE 200
MAITLAND FL
32751-6114
US

IV. Provider business mailing address

1033 DR MARTIN LUTHER KING JR ST N SUITE 108
ST PETERSBURG FL
33701-1547
US

V. Phone/Fax

Practice location:
  • Phone: 407-767-6411
  • Fax: 407-767-8160
Mailing address:
  • Phone: 727-456-3288
  • Fax: 727-456-3289

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number
License Number State

VIII. Authorized Official

Name: SHEILA A TATHAM
Title or Position: CREDENTIALING MANAGER
Credential:
Phone: 727-456-4250