Basic Information
| Provider Information | |||||||||
| NPI: | 1952358418 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | VARIETY CHILDREN'S HOSPITAL | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | NICKLAUS CHILDREN'S HOSPITAL | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 865095 | ||||||||
| Address2: | |||||||||
| City: | ORLANDO | ||||||||
| State: | FL | ||||||||
| PostalCode: | 328865095 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7866245876 | ||||||||
| FaxNumber: | 7866242688 | ||||||||
| Practice Location | |||||||||
| Address1: | 3100 SW 62ND AVE | ||||||||
| Address2: | |||||||||
| City: | MIAMI | ||||||||
| State: | FL | ||||||||
| PostalCode: | 331553009 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3056666511 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 05/30/2006 | ||||||||
| LastUpdateDate: | 10/14/2016 | ||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | FRANCE | ||||||||
| AuthorizedOfficialFirstName: | REBECCA | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | ADMINISTRATIVE DIRECTOR., RCM | ||||||||
| AuthorizedOfficialTelephone: | 7866245876 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | NICKLAUS CHILDREN'S HOSPITAL- PSYCHIATRY | ||||||||
| AuthorizedOfficialNamePrefix: | MS. | ||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2084P0804X | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Child & Adolescent Psychiatry |
ID Information
| ID | Type | State | Issuer | Description | 269333000 | 05 | FL | MEDICAID |