MEDICARE: PEDIATRIC RHEUMATOLOGY ASSOCIATES LLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy
1	291U00000X	Clinical Medical Laboratory
2	261Q00000X	Clinic/Center
3	261QI0500X	Infusion Therapy Clinic/Center
4	332900000X	Non-Pharmacy Dispensing Site
5	261QM2500X	Medical Specialty Clinic/Center

General Provider Information

NPI Number	:	1467085902
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	PEDIATRIC RHEUMATOLOGY ASSOCIATES LLC

Provider Business Mailing Address
First Line	:	29939 ONO BLVD
Second Line	:
City	:	ORANGE BEACH
State	:	AL
Zip	:	36561-3634
Country	:	US
Telephone Number	:	501-231-4367
Fax Number	:

Provider Business Practice Location Address
First Line	:	12591 SORRENTO RD STE A
Second Line	:
City	:	PENSACOLA
State	:	FL
Zip	:	32507-8754
Country	:	US
Telephone Number	:	850-262-8645
Fax Number	:	850-262-8647

Authorized Official
Title or Position	:	CEO
Name	:	MR. ADAM KUETTEL
Credential	:
Telephone Number	:	850-262-8645

Provider Enumeration Date	:	02/12/2020
Last Update Date	:	10/07/2020

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