MEDICARE: TOTAL PEDIATRIC HEALTHCAREII

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	208000000X	Pediatrics Physician	ME72163	FL

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	2321757001	OTHER		CIGNA
2	01106700	OTHER	FL	AMERIGROUP
3	10880601	OTHER	FL	CITRUSCAID
4	225385	OTHER		WELLCARE
5	41515	OTHER	FL	BLUE CROSS BLUE SHIELD
6	132800	OTHER	FL	AETNA
7	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1487880977
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	TOTAL PEDIATRIC HEALTHCAREII

Provider Business Mailing Address
First Line	:	5337 N SOCRUM LOOP RD
Second Line	:	320
City	:	LAKELAND
State	:	FL
Zip	:	33809-4256
Country	:	US
Telephone Number	:	863-815-3775
Fax Number	:	863-815-3765

Provider Business Practice Location Address
First Line	:	930 MARCUM RD
Second Line	:
City	:	LAKELAND
State	:	FL
Zip	:	33809-4308
Country	:	US
Telephone Number	:	863-815-3775
Fax Number	:	863-815-3765

Authorized Official
Title or Position	:	PRESIDENT
Name	:	DR. STEWART A GRANT
Credential	:	M.D.
Telephone Number	:	863-815-3775

Provider Enumeration Date	:	06/10/2009
Last Update Date	:	06/10/2009

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