MEDICARE: MANOR PLAZA PEDIATRIC CENTER INC

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	208D00000X	General Practice Physician	ME0042195	FL
2	208000000X	Pediatrics Physician	ME0042195	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	:	1558657130
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	MANOR PLAZA PEDIATRIC CENTER INC

Provider Business Mailing Address
First Line	:	1234 NE 4TH AVE
Second Line	:
City	:	FORT LAUDERDALE
State	:	FL
Zip	:	33304-1925
Country	:	US
Telephone Number	:	954-779-1667
Fax Number	:	954-760-7253

Provider Business Practice Location Address
First Line	:	1234 NE 4TH AVE
Second Line	:
City	:	FORT LAUDERDALE
State	:	FL
Zip	:	33304-1925
Country	:	US
Telephone Number	:	954-779-1667
Fax Number	:	954-760-7253

Authorized Official
Title or Position	:	MEDICAL DIRECTOR
Name	:	JEAN-WILNER MATHIEU
Credential	:	M.D.
Telephone Number	:	954-779-1667

Provider Enumeration Date	:	06/22/2011
Last Update Date	:	02/16/2012

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Directions to “MANOR PLAZA PEDIATRIC CENTER INC ” Practice Location

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