Basic Information
| Provider Information | |||||||||
| NPI: | 1164445367 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | PEDIATRIX CARDIOLOGY OF WASHINGTON, P.C. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1301 CONCORD TER | ||||||||
| Address2: | |||||||||
| City: | SUNRISE | ||||||||
| State: | FL | ||||||||
| PostalCode: | 333232843 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8002433839 | ||||||||
| FaxNumber: | 8446862961 | ||||||||
| Practice Location | |||||||||
| Address1: | 314 MARTIN LUTHER KING JR WAY | ||||||||
| Address2: | STE. 303 | ||||||||
| City: | TACOMA | ||||||||
| State: | WA | ||||||||
| PostalCode: | 984054250 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2533964868 | ||||||||
| FaxNumber: | 2533964870 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/26/2006 | ||||||||
| LastUpdateDate: | 07/07/2021 | ||||||||
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| AuthorizedOfficialLastName: | MARTIN | ||||||||
| AuthorizedOfficialFirstName: | JAY | ||||||||
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| AuthorizedOfficialTitleorPosition: | ASSISTANT SECRETARY | ||||||||
| AuthorizedOfficialTelephone: | 8002433839 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| NPICertificationDate: | 07/07/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2080P0202X | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Pediatrics | Pediatric Cardiology |
ID Information
| ID | Type | State | Issuer | Description | MDG20WA | 05 | AK | MEDICAID | 1164445367 | 05 | WA | MEDICAID | 1164445367 | 05 | ID | MEDICAID |