=====================================================
General NPI Number Information
=====================================================
NPI Number | 1528101557
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | KIDS CARE PEDIATRICS OF NW FL INC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 02/15/2007
-----------------------------------------------------
Last Update Date | 08/22/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 7552 NAVARRE PKWY UNIT 18
-----------------------------------------------------
City | NAVARRE
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 32566-7308
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 850-936-4543
-----------------------------------------------------
Fax | 850-936-8543
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 4622 SUMMERDALE BLVD
-----------------------------------------------------
City | PACE
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 32571
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 850-995-0169
-----------------------------------------------------
Fax | 850-995-2649
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT
-----------------------------------------------------
Name | DR. JENNIFER M ZIMMERMAN
-----------------------------------------------------
Credential | M.D.
-----------------------------------------------------
Telephone | 850-995-0169
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 208000000X
-----------------------------------------------------
Taxonomy Name | Pediatrics Physician
-----------------------------------------------------
License Number | ME0075074
-----------------------------------------------------
License Number State | FL
-----------------------------------------------------