Healthcare Provider Details

I. General information

NPI: 1982712667
Provider Name (Legal Business Name): CHILDRENS CRITICAL CARE ASSOCIATES
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/25/2006
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1814 LUCERNE TER SUITE C
ORLANDO FL
32806-2949
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: 727-767-4755
  • Fax:
Mailing address:
  • Phone: 727-456-3288
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2080P0203X
TaxonomyPediatric Critical Care Medicine Physician
License Number
License Number State

VIII. Authorized Official

Name: KRISTY STEWART
Title or Position: CREDENTIALING COORDINATOR
Credential:
Phone: 727-456-4250