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General NPI Number Information
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NPI Number | 1639447352
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Entity Type | Organization
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Legal Business Name | TOTAL PEDIATRIC HEALTHCARE
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Dates
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Enumeration Date | 12/08/2011
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Last Update Date | 12/12/2011
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Provider Practice Location Address
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Address Line | 203 KINGSWAY RD STE A
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City | BRANDON
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State | FL
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Zip | 33510-4679
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Country | US
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Telephone | 813-655-5106
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Fax |
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Provider Business Mailing Address
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Address Line | 16765 FISHHAWK BLVD # 314
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City | LITHIA
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State | FL
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Zip | 33547-3860
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Country | US
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Telephone | 813-655-5106
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Fax |
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Authorized Official
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Title or Position | OWNER
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Name | DR. STEWART AUBREY GRANT
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Credential | M.D.
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Telephone | 813-655-5106
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 261Q00000X
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Taxonomy Name | Clinic/Center
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License Number | ME72163
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License Number State | FL
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