Healthcare Provider Details

I. General information

NPI: 1396962734
Provider Name (Legal Business Name): FLORIDA PEDIATRIC GROUP PA
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/19/2007
Last Update Date: 02/20/2025
Certification Date: 02/20/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

250 S WICKHAM RD
W MELBOURNE FL
32904-1134
US

IV. Provider business mailing address

250 S WICKHAM RD
W MELBOURNE FL
32904-1134
US

V. Phone/Fax

Practice location:
  • Phone: 321-752-5210
  • Fax: 321-752-5388
Mailing address:
  • Phone: 321-752-5210
  • Fax: 321-752-5388

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberME81059
License Number StateFL

VIII. Authorized Official

Name: DEE DEE SCHULTZ
Title or Position: BILLING DEPARTMENT
Credential:
Phone: 321-752-5210