=====================================================
General NPI Number Information
=====================================================
NPI Number | 1194066761
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | COMPASSION PEDIATRICS LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/07/2013
-----------------------------------------------------
Last Update Date | 10/24/2023
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 4445 S SEMORAN BLVD STE A
-----------------------------------------------------
City | ORLANDO
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 32822-2472
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 407-203-8957
-----------------------------------------------------
Fax | 407-985-1904
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 4445 S SEMORAN BLVD STE A
-----------------------------------------------------
City | ORLANDO
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 32822-2472
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 407-203-8957
-----------------------------------------------------
Fax | 407-985-1904
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | CEO
-----------------------------------------------------
Name | DR. LESLEY KYLE BOW
-----------------------------------------------------
Credential | MD
-----------------------------------------------------
Telephone | 407-456-4591
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 101YP2500X
-----------------------------------------------------
Taxonomy Name | Professional Counselor
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 363AM0700X
-----------------------------------------------------
Taxonomy Name | Medical Physician Assistant
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #3
-----------------------------------------------------
Taxonomy Code | 363LF0000X
-----------------------------------------------------
Taxonomy Name | Family Nurse Practitioner
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #4
-----------------------------------------------------
Taxonomy Code | 363LP0200X
-----------------------------------------------------
Taxonomy Name | Pediatric Nurse Practitioner
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #5
-----------------------------------------------------
Taxonomy Code | 208000000X
-----------------------------------------------------
Taxonomy Name | Pediatrics Physician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------