Healthcare Provider Details

I. General information

NPI: 1134569049
Provider Name (Legal Business Name): RAINBOW PEDIATRICS PC LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/25/2013
Last Update Date: 09/23/2021
Certification Date: 09/23/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

200 FOREST PARK CIR
PANAMA CITY FL
32405-4915
US

IV. Provider business mailing address

PO BOX 578
LYNN HAVEN FL
32444-0578
US

V. Phone/Fax

Practice location:
  • Phone: 850-257-5524
  • Fax: 850-257-5638
Mailing address:
  • Phone: 850-767-4777
  • Fax: 850-763-4988

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberME105520
License Number StateFL
# 2
Primary TaxonomyN
Taxonomy Code2080A0000X
TaxonomyPediatric Adolescent Medicine Physician
License NumberME105520
License Number StateFL
# 3
Primary TaxonomyN
Taxonomy Code2080N0001X
TaxonomyNeonatal-Perinatal Medicine Physician
License NumberME105520
License Number StateFL

VIII. Authorized Official

Name: DR. AHMED REZK
Title or Position: OWNER
Credential: M.D.
Phone: 973-356-6245