Provider Demographics
NPI:1316349905
Name:TOTAL PEDIATRIC CARE
Entity type:Organization
Organization Name:TOTAL PEDIATRIC CARE
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:JEANETTA
Authorized Official - Middle Name:
Authorized Official - Last Name:FLOOD
Authorized Official - Suffix:
Authorized Official - Credentials:MA
Authorized Official - Phone:954-351-0202
Mailing Address - Street 1:100 E COMMERCIAL BLVD
Mailing Address - Street 2:
Mailing Address - City:FT LAUDERDALE
Mailing Address - State:FL
Mailing Address - Zip Code:33334-1687
Mailing Address - Country:US
Mailing Address - Phone:954-351-0202
Mailing Address - Fax:954-351-0201
Practice Address - Street 1:100 E COMMERCIAL BLVD
Practice Address - Street 2:
Practice Address - City:FT LAUDERDALE
Practice Address - State:FL
Practice Address - Zip Code:33334-1687
Practice Address - Country:US
Practice Address - Phone:954-351-0202
Practice Address - Fax:954-351-0201
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-09-25
Last Update Date:2014-09-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME0060159208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL370024101Medicaid