Healthcare Provider Details

I. General information

NPI: 1679037790
Provider Name (Legal Business Name): PEDIATRIC SPECIALTY GROUP, INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/23/2019
Last Update Date: 01/24/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3445 NW 7TH ST
MIAMI FL
33125-4013
US

IV. Provider business mailing address

3100 SW 62ND AVE
MIAMI FL
33155-3009
US

V. Phone/Fax

Practice location:
  • Phone: 305-643-0133
  • Fax:
Mailing address:
  • Phone: 305-643-0133
  • Fax: 305-643-1728

VI. Provider taxonomy

Scope of Practice (Provider specialty)

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

VIII. Authorized Official

Name: RAIZA BEATRIZ VIDAURRAZAGA
Title or Position: SR PROVIDER RELATIONS SPECIALIST
Credential:
Phone: 786-624-2186