Healthcare Provider Details

I. General information

NPI: 1124325154
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

1850 CROSSINGS BLVD UNIT 100
ODESSA FL
33556-6106
US

IV. Provider business mailing address

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

V. Phone/Fax

Practice location:
  • Phone: 813-475-7100
  • Fax: 813-475-7119
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 NumberME65867
License Number StateFL

VIII. Authorized Official

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