Provider Demographics
NPI:1487880977
Name:TOTAL PEDIATRIC HEALTHCAREII
Entity type:Organization
Organization Name:TOTAL PEDIATRIC HEALTHCAREII
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:STEWART
Authorized Official - Middle Name:A
Authorized Official - Last Name:GRANT
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:863-815-3775
Mailing Address - Street 1:5337 N SOCRUM LOOP RD
Mailing Address - Street 2:320
Mailing Address - City:LAKELAND
Mailing Address - State:FL
Mailing Address - Zip Code:33809-4256
Mailing Address - Country:US
Mailing Address - Phone:863-815-3775
Mailing Address - Fax:863-815-3765
Practice Address - Street 1:930 MARCUM RD
Practice Address - Street 2:
Practice Address - City:LAKELAND
Practice Address - State:FL
Practice Address - Zip Code:33809-4308
Practice Address - Country:US
Practice Address - Phone:863-815-3775
Practice Address - Fax:863-815-3765
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-06-10
Last Update Date:2009-06-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME72163208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
2321757001OtherCIGNA
FL01106700OtherAMERIGROUP
FL10880601OtherCITRUSCAID
225385OtherWELLCARE
FL41515OtherBLUE CROSS BLUE SHIELD
FL132800OtherAETNA
FL268531100Medicaid