=====================================================
General NPI Number Information
=====================================================
NPI Number | 1275554248
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | PEDIATRIC PROVIDERS OF S FLORIDA
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/22/2006
-----------------------------------------------------
Last Update Date | 08/22/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 464 W 51ST PL
-----------------------------------------------------
City | HIALEAH
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33012-3620
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 305-551-1281
-----------------------------------------------------
Fax | 305-362-9138
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 464 W 51ST PL
-----------------------------------------------------
City | HIALEAH
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33012-3620
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | MANAGED CARE SPEC- ALLSCRIPTS
-----------------------------------------------------
Name | DIRENDIA SHACKELFORD
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 800-680-0889
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 332900000X
-----------------------------------------------------
Taxonomy Name | Non-Pharmacy Dispensing Site
-----------------------------------------------------
License Number | ME49402
-----------------------------------------------------
License Number State | FL
-----------------------------------------------------