Basic Information
| Provider Information | |||||||||
| NPI: | 1518681337 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | PEDIATRIC SPECIALTY GROUP, INC. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3100 SW 62ND AVE | ||||||||
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| City: | MIAMI | ||||||||
| State: | FL | ||||||||
| PostalCode: | 331553009 | ||||||||
| CountryCode: | US | ||||||||
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| Address1: | 3100 SW 62ND AVE | ||||||||
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| City: | MIAMI | ||||||||
| State: | FL | ||||||||
| PostalCode: | 331553009 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3056666511 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 09/27/2022 | ||||||||
| LastUpdateDate: | 09/27/2022 | ||||||||
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| AuthorizedOfficialLastName: | GABER | ||||||||
| AuthorizedOfficialFirstName: | LAURA | ||||||||
| AuthorizedOfficialMiddleName: | M | ||||||||
| AuthorizedOfficialTitleorPosition: | PROVIDER RELATIONS SPECIALIST | ||||||||
| AuthorizedOfficialTelephone: | 7866245747 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| NPICertificationDate: | 09/23/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 367H00000X | Y | 193200000X MULTI-SPECIALTY GROUP | Physician Assistants & Advanced Practice Nursing Providers | Anesthesiologist Assistant |
ID Information
| ID | Type | State | Issuer | Description | 013515238 | 05 | FL | MEDICAID |