=====================================================
General NPI Number Information
=====================================================
NPI Number | 1376846733
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | FLORIDA PEDIATRIC ASSOCIATES, LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 12/07/2010
-----------------------------------------------------
Last Update Date | 12/07/2010
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 790 CONCOURSE PKWY S SUITE 200
-----------------------------------------------------
City | MAITLAND
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 32751-6114
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 407-767-6411
-----------------------------------------------------
Fax | 407-767-8160
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1033 DR MARTIN LUTHER KING JR ST N SUITE 108
-----------------------------------------------------
City | ST PETERSBURG
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33701-1547
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 727-456-3288
-----------------------------------------------------
Fax | 727-456-3289
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | CREDENTIALING MANAGER
-----------------------------------------------------
Name | SHEILA A TATHAM
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 727-456-4250
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 208000000X
-----------------------------------------------------
Taxonomy Name | Pediatrics Physician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------