Basic Information
Provider Information | |||||||||
NPI: | 1144327859 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | PEDIATRIX MEDICAL GROUP OF WASHINGTON INC PS | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 1301 CONCORD TER | ||||||||
Address2: |   | ||||||||
City: | SUNRISE | ||||||||
State: | FL | ||||||||
PostalCode: | 333232843 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 9543840175 | ||||||||
FaxNumber: | 9548511948 | ||||||||
Practice Location | |||||||||
Address1: | 770 THE CITY DR S | ||||||||
Address2: | SUITE 4000 | ||||||||
City: | ORANGE | ||||||||
State: | CA | ||||||||
PostalCode: | 928684900 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8004636628 | ||||||||
FaxNumber: | 7147400326 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 09/17/2006 | ||||||||
LastUpdateDate: | 07/09/2021 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | MARTIN | ||||||||
AuthorizedOfficialFirstName: | JAY | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: | ASSISTANT SECRETARY | ||||||||
AuthorizedOfficialTelephone: | 9543840175 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 07/09/2021 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2080P0203X |   |   | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Pediatrics | Pediatric Critical Care Medicine | 363LN0000X |   |   | N | 193200000X MULTI-SPECIALTY GROUP | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Neonatal | 2080N0001X |   |   | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Pediatrics | Neonatal-Perinatal Medicine |
ID Information
ID | Type | State | Issuer | Description | 7083041 | 05 | WA |   | MEDICAID | MDG69WA | 05 | AK |   | MEDICAID | 7097421 | 05 | WA |   | MEDICAID | 7094139 | 05 | WA |   | MEDICAID | 7129364 | 05 | WA |   | MEDICAID | MDG65WA | 05 | AK |   | MEDICAID | MDG68WA | 05 | AK |   | MEDICAID | MDG66WA | 05 | AK |   | MEDICAID | 806317100 | 05 | ID |   | MEDICAID |