Provider Demographics
NPI:1124369160
Name:PEDIATRIC ASSOCIATES PA
Entity type:Organization
Organization Name:PEDIATRIC ASSOCIATES PA
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRACTICES ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:DEBBIE
Authorized Official - Middle Name:
Authorized Official - Last Name:CHAVERS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:850-478-1100
Mailing Address - Street 1:4435 HIGHWAY 90
Mailing Address - Street 2:
Mailing Address - City:PACE
Mailing Address - State:FL
Mailing Address - Zip Code:32571-2066
Mailing Address - Country:US
Mailing Address - Phone:850-994-0901
Mailing Address - Fax:850-994-2740
Practice Address - Street 1:4435 HIGHWAY 90
Practice Address - Street 2:
Practice Address - City:PACE
Practice Address - State:FL
Practice Address - Zip Code:32571-2066
Practice Address - Country:US
Practice Address - Phone:850-994-0901
Practice Address - Fax:850-994-2737
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:PEDIATRIC ASSOCIATES PA
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2013-03-14
Last Update Date:2018-03-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL280234101Medicaid