MEDICARE: SUNSHINE PEDIATRIC CLINIC 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	ME85827	FL

General Provider Information

NPI Number	:	1811396419
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	SUNSHINE PEDIATRIC CLINIC PA

Provider Business Mailing Address
First Line	:	1973 SW SAVAGE BLVD
Second Line	:	SUITE 205
City	:	PORT ST LUCIE
State	:	FL
Zip	:	34953-2791
Country	:	US
Telephone Number	:	772-446-7800
Fax Number	:	772-446-7891

Provider Business Practice Location Address
First Line	:	1973 SW SAVAGE BLVD
Second Line	:	SUITE 205
City	:	PORT ST LUCIE
State	:	FL
Zip	:	34953-2791
Country	:	US
Telephone Number	:	772-446-7800
Fax Number	:	772-446-7891

Authorized Official
Title or Position	:	PRESIDENT
Name	:	DR. KABIR AHMED
Credential	:	M.D
Telephone Number	:	772-446-7800

Provider Enumeration Date	:	08/19/2014
Last Update Date	:	08/19/2014

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