MEDICARE: PEDIATRIC NEUROLOGY CENTER

Medicare Provider Information

Scope of Practice

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

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	2080P0008X	Pediatric Neurodevelopmental Disabilities Physician
2	2084N0402X	Neurology with Special Qualifications in Child Neurology Physician	ME 87941	FL

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
2	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1477539807
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	PEDIATRIC NEUROLOGY CENTER

Provider Business Mailing Address
First Line	:	5133 SOUTH LAKELAND DRIVE
Second Line	:
City	:	LAKELAND
State	:	FL
Zip	:	33813
Country	:	US
Telephone Number	:	888-362-2343
Fax Number	:	888-388-1340

Provider Business Practice Location Address
First Line	:	5133 SOUTH LAKELAND DRIVE
Second Line	:
City	:	LAKELAND
State	:	FL
Zip	:	33813
Country	:	US
Telephone Number	:	888-362-2343
Fax Number	:	888-388-1340

Authorized Official
Title or Position	:	PRESIDENT
Name	:	DR. MUSARRAT N QURESHI
Credential	:	M.D.
Telephone Number	:	888-362-2343

Provider Enumeration Date	:	12/18/2005
Last Update Date	:	06/17/2010

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