MEDICARE: ANGEL KIDS PA

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

General Provider Information

NPI Number	:	1598331563
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	ANGEL KIDS PA

Provider Business Mailing Address
First Line	:	13241 BARTRAM PARK BLVD UNIT 209
Second Line	:
City	:	JACKSONVILLE
State	:	FL
Zip	:	32258-5233
Country	:	US
Telephone Number	:	904-242-4220
Fax Number	:

Provider Business Practice Location Address
First Line	:	2040 RIVERVIEW ST
Second Line	:
City	:	JACKSONVILLE
State	:	FL
Zip	:	32208-2657
Country	:	US
Telephone Number	:	904-242-4220
Fax Number	:

Authorized Official
Title or Position	:	BILLING/CREDENTIALING MANANGER
Name	:	AZZA GHANDOUR
Credential	:
Telephone Number	:	904-242-4220

Provider Enumeration Date	:	06/01/2021
Last Update Date	:	06/01/2021

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Directions to “ANGEL KIDS PA ” Practice Location

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