Provider Demographics
NPI:1124488127
Name:PSA PEDIATRIC NEPHROLOGY
Entity type:Organization
Organization Name:PSA PEDIATRIC NEPHROLOGY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:SVP & CFO FOR MCHS
Authorized Official - Prefix:MR
Authorized Official - First Name:TIMOTHY
Authorized Official - Middle Name:
Authorized Official - Last Name:BIRKENSTOCK
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:305-669-6422
Mailing Address - Street 1:3100 SW 62ND AVE
Mailing Address - Street 2:
Mailing Address - City:MIAMI
Mailing Address - State:FL
Mailing Address - Zip Code:33155-3009
Mailing Address - Country:US
Mailing Address - Phone:305-662-8352
Mailing Address - Fax:305-669-6545
Practice Address - Street 1:1665 MEDICAL BLVD
Practice Address - Street 2:
Practice Address - City:NAPLES
Practice Address - State:FL
Practice Address - Zip Code:34110-1402
Practice Address - Country:US
Practice Address - Phone:305-662-8352
Practice Address - Fax:305-669-6545
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:PEDIATRIC SPECIALTY GROUP, INC.
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2016-03-03
Last Update Date:2016-03-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RN0300XAllopathic & Osteopathic PhysiciansInternal MedicineNephrologyGroup - Single Specialty