MEDICARE: KIDS' CORNER PEDIATRICS

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

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	:	1720603129
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	KIDS' CORNER PEDIATRICS

Provider Business Mailing Address
First Line	:	1114 BELL SHOALS RD
Second Line	:
City	:	BRANDON
State	:	FL
Zip	:	33511-8813
Country	:	US
Telephone Number	:	813-940-8140
Fax Number	:	813-940-8148

Provider Business Practice Location Address
First Line	:	1114 BELL SHOALS ROAD
Second Line	:
City	:	BRANDON
State	:	FL
Zip	:	33511-8813
Country	:	US
Telephone Number	:	813-940-8140
Fax Number	:	813-940-8148

Authorized Official
Title or Position	:	OWNER
Name	:	EVER I RIVERA
Credential	:	MD
Telephone Number	:	813-940-8140

Provider Enumeration Date	:	06/11/2020
Last Update Date	:	07/27/2020

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