Healthcare Provider Details

I. General information

NPI: 1518626985
Provider Name (Legal Business Name): PEDIATRIC SPECIALTY GROUP, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/14/2021
Last Update Date: 12/14/2021
Certification Date: 12/14/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

17615 SW 97TH AVE
PALMETTO BAY FL
33157-5636
US

IV. Provider business mailing address

3100 SW 62ND AVE
MIAMI FL
33155-3009
US

V. Phone/Fax

Practice location:
  • Phone: 305-669-6505
  • Fax: 305-668-5591
Mailing address:
  • Phone: 305-666-6511
  • Fax: 305-662-8291

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code2080A0000X
TaxonomyPediatric Adolescent Medicine Physician
License Number
License Number State

VIII. Authorized Official

Name: LAURA M GABER
Title or Position: PROVIDER RELATIONS SPECIALIST
Credential:
Phone: 786-624-5747