MEDICARE: PALM HARBOR PEDIATRIC URGENT CARE CENTER 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	261QU0200X	Urgent Care Clinic/Center

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	282538	OTHER		AVMED
2	B903Q	OTHER	FL	BCBS
3	196501	OTHER	FL	WELLCARE
4	220597	OTHER		AMERIGROUP
5	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1720179120
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	PALM HARBOR PEDIATRIC URGENT CARE CENTER PA

Provider Business Mailing Address
First Line	:	PO BOX 23863
Second Line	:
City	:	TAMPA
State	:	FL
Zip	:	33623-3863
Country	:	US
Telephone Number	:	727-823-2188
Fax Number	:	727-823-9502

Provider Business Practice Location Address
First Line	:	36458 US HIGHWAY 19 N
Second Line	:
City	:	PALM HARBOR
State	:	FL
Zip	:	34684-1330
Country	:	US
Telephone Number	:	727-787-5439
Fax Number	:	727-787-6221

Authorized Official
Title or Position	:	PROVIDER/OWNER
Name	:	LUIS MARAMARA
Credential	:	MD
Telephone Number	:	727-787-5439

Provider Enumeration Date	:	09/28/2006
Last Update Date	:	12/03/2008

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