Healthcare Provider Details

I. General information

NPI: 1598229890
Provider Name (Legal Business Name): PEDIATRIC SPECIALTY GROUP, INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/31/2019
Last Update Date: 01/31/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3228 SW MARTIN DOWNS BLVD
PALM CITY FL
34990-2679
US

IV. Provider business mailing address

3100 SW 62ND AVE
MIAMI FL
33155-3009
US

V. Phone/Fax

Practice location:
  • Phone: 772-286-8133
  • Fax:
Mailing address:
  • Phone: 772-286-8133
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2080I0007X
TaxonomyPediatric Clinical & Laboratory Immunology Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code2080P0202X
TaxonomyPediatric Cardiology Physician
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code2080P0205X
TaxonomyPediatric Endocrinology Physician
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code2080P0206X
TaxonomyPediatric Gastroenterology Physician
License Number
License Number State
# 5
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