Healthcare Provider Details

I. General information

NPI: 1467761262
Provider Name (Legal Business Name): PEDIATRIC GROUP
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/28/2010
Last Update Date: 09/28/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2420 JENKS AVE UNIT 3
PANAMA CITY FL
32405-4910
US

IV. Provider business mailing address

PO BOX 1430
LYNN HAVEN FL
32444-6230
US

V. Phone/Fax

Practice location:
  • Phone: 850-767-4777
  • Fax: 850-763-4988
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 NumberME92242
License Number StateFL

VIII. Authorized Official

Name: DR. AHMED M BAKER
Title or Position: PHYSICIAN
Credential: M.D.
Phone: 850-767-4777