Basic Information
| Provider Information | |||||||||
| NPI: | 1285389288 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | PEDIATRIC SPECIALTY GROUP, INC. | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | NICKLAUS CHILDREN'S PEDIATRIC SPECIALISTS - NEUROLOGY | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3100 SW 62ND AVE | ||||||||
| Address2: | |||||||||
| City: | MIAMI | ||||||||
| State: | FL | ||||||||
| PostalCode: | 331553009 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3056666511 | ||||||||
| FaxNumber: | 3056628291 | ||||||||
| Practice Location | |||||||||
| Address1: | 3100 SW 62ND AVE | ||||||||
| Address2: | |||||||||
| City: | MIAMI | ||||||||
| State: | FL | ||||||||
| PostalCode: | 331553009 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3056666511 | ||||||||
| FaxNumber: | 3056628291 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/17/2022 | ||||||||
| LastUpdateDate: | 06/03/2022 | ||||||||
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| AuthorizedOfficialLastName: | GABER | ||||||||
| AuthorizedOfficialFirstName: | LAURA | ||||||||
| AuthorizedOfficialMiddleName: | M | ||||||||
| AuthorizedOfficialTitleorPosition: | PROVIDER RELATIONS SPECIALIST | ||||||||
| AuthorizedOfficialTelephone: | 7866245747 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | PEDIATRIC SPECIALTY GROUP, INC. | ||||||||
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| NPICertificationDate: | 06/03/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207T00000X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Neurological Surgery | 2084N0402X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Neurology with Special Qualifications in Child Neurology | 2080P0008X | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Pediatrics | Neurodevelopmental Disabilities |
No ID Information.