Provider Demographics
NPI:1215329313
Name:PERSONALIZED PEDIATRICS LLC
Entity type:Organization
Organization Name:PERSONALIZED PEDIATRICS LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/FOUNDER
Authorized Official - Prefix:DR
Authorized Official - First Name:EDNA
Authorized Official - Middle Name:L
Authorized Official - Last Name:TELLO
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:954-632-2791
Mailing Address - Street 1:1440 CORAL RIDGE DR # 121
Mailing Address - Street 2:
Mailing Address - City:CORAL SPRINGS
Mailing Address - State:FL
Mailing Address - Zip Code:33071-5433
Mailing Address - Country:US
Mailing Address - Phone:954-632-2791
Mailing Address - Fax:954-752-7845
Practice Address - Street 1:12621 NW 8TH CT
Practice Address - Street 2:
Practice Address - City:CORAL SPRINGS
Practice Address - State:FL
Practice Address - Zip Code:33071-4425
Practice Address - Country:US
Practice Address - Phone:954-632-2791
Practice Address - Fax:954-752-7845
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-02-26
Last Update Date:2015-02-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME80694208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL2606259Medicaid