Basic Information
| Provider Information | |||||||||
| NPI: | 1235774852 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | PEDIATRIC SPECIALTY GROUP, INC. | ||||||||
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| OtherOrganizationName: | PEDIATRIC SPECIALISTS OF AMERICA - PHYSICAL MEDICINE AND REHABLITATION | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 865095 | ||||||||
| Address2: | |||||||||
| City: | ORLANDO | ||||||||
| State: | FL | ||||||||
| PostalCode: | 328865095 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7866245712 | ||||||||
| FaxNumber: | 3056685539 | ||||||||
| Practice Location | |||||||||
| Address1: | 3100 SW 62ND AVE | ||||||||
| Address2: | 1ST FLOOR, TRAUMA UNIT | ||||||||
| City: | MIAMI | ||||||||
| State: | FL | ||||||||
| PostalCode: | 331553009 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3056666511 | ||||||||
| FaxNumber: | 3056628291 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/07/2019 | ||||||||
| LastUpdateDate: | 12/09/2019 | ||||||||
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| AuthorizedOfficialLastName: | GABER | ||||||||
| AuthorizedOfficialFirstName: | LAURA | ||||||||
| AuthorizedOfficialMiddleName: | M | ||||||||
| AuthorizedOfficialTitleorPosition: | PROVIDER RELATIONS SPECIALIST | ||||||||
| AuthorizedOfficialTelephone: | 7866245747 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| NPICertificationDate: | 12/09/2019 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2080P0203X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Pediatrics | Pediatric Critical Care Medicine | 2080P0204X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Pediatrics | Pediatric Emergency Medicine | 208100000X | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Physical Medicine & Rehabilitation |
No ID Information.