Basic Information
| Provider Information | |||||||||
| NPI: | 1033194816 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | PEDIATRIC SURGICAL GROUP, P.A. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 880 6TH ST S | ||||||||
| Address2: | SUITE 210 | ||||||||
| City: | ST PETERSBURG | ||||||||
| State: | FL | ||||||||
| PostalCode: | 337014827 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7277674170 | ||||||||
| FaxNumber: | 7277674346 | ||||||||
| Practice Location | |||||||||
| Address1: | 880 6TH ST S | ||||||||
| Address2: | SUITE 210 | ||||||||
| City: | ST PETERSBURG | ||||||||
| State: | FL | ||||||||
| PostalCode: | 337014827 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7277674170 | ||||||||
| FaxNumber: | 7277674346 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/14/2005 | ||||||||
| LastUpdateDate: | 08/22/2020 | ||||||||
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| AuthorizedOfficialLastName: | CLARK | ||||||||
| AuthorizedOfficialFirstName: | CATHY | ||||||||
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| AuthorizedOfficialTitleorPosition: | PRACTICE MANAGER | ||||||||
| AuthorizedOfficialTelephone: | 7277673221 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MRS. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2086S0120X | ME0055290 | FL | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Surgery | Pediatric Surgery |
No ID Information.