Provider Demographics
NPI:1104814185
Name:KIDS CARE PEDIATRICS,PA
Entity type:Organization
Organization Name:KIDS CARE PEDIATRICS,PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRACTICE ADVISOR
Authorized Official - Prefix:MR
Authorized Official - First Name:OWEN
Authorized Official - Middle Name:MARK
Authorized Official - Last Name:ROSENBERG
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:386-325-9811
Mailing Address - Street 1:6910 OLD WOLF BAY RD
Mailing Address - Street 2:
Mailing Address - City:PALATKA
Mailing Address - State:FL
Mailing Address - Zip Code:32177-6800
Mailing Address - Country:US
Mailing Address - Phone:386-328-7337
Mailing Address - Fax:
Practice Address - Street 1:6910 OLD WOLF BAY RD
Practice Address - Street 2:
Practice Address - City:PALATKA
Practice Address - State:FL
Practice Address - Zip Code:32177-6800
Practice Address - Country:US
Practice Address - Phone:386-328-7337
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-10-12
Last Update Date:2021-03-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL107889601Medicaid
FL72696OtherBLUE CROSS BLUE SHIELD FL