Healthcare Provider Details

I. General information

NPI: 1124488127
Provider Name (Legal Business Name): PSA PEDIATRIC NEPHROLOGY
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/03/2016
Last Update Date: 03/03/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1665 MEDICAL BLVD
NAPLES FL
34110-1402
US

IV. Provider business mailing address

3100 SW 62ND AVE
MIAMI FL
33155-3009
US

V. Phone/Fax

Practice location:
  • Phone: 305-662-8352
  • Fax: 305-669-6545
Mailing address:
  • Phone: 305-662-8352
  • Fax: 305-669-6545

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RN0300X
TaxonomyNephrology Physician
License Number
License Number State

VIII. Authorized Official

Name: MR. TIMOTHY BIRKENSTOCK
Title or Position: SVP & CFO FOR MCHS
Credential:
Phone: 305-669-6422