MEDICARE: PERSONAL PEDIATRIC CARE PLLC

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	ME58972	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

General Provider Information

NPI Number	:	1578860078
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	PERSONAL PEDIATRIC CARE PLLC

Provider Business Mailing Address
First Line	:	3012 STARKEY BLVD
Second Line	:
City	:	TRINITY
State	:	FL
Zip	:	34655-2175
Country	:	US
Telephone Number	:	727-645-6941
Fax Number	:	727-494-7684

Provider Business Practice Location Address
First Line	:	3012 STARKEY BLVD
Second Line	:
City	:	TRINITY
State	:	FL
Zip	:	34655-2175
Country	:	US
Telephone Number	:	727-645-6941
Fax Number	:	727-494-7684

Authorized Official
Title or Position	:	PHYSICIAN
Name	:	JAY MICHAEL HARVEY
Credential	:	M.D.
Telephone Number	:	727-645-6941

Provider Enumeration Date	:	02/17/2011
Last Update Date	:	02/17/2011

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