Provider Demographics
NPI:1528160306
Name:WEST HIALEAH PEDIATRIC ASSOCIATES, PA
Entity type:Organization
Organization Name:WEST HIALEAH PEDIATRIC ASSOCIATES, PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:EDUARDO
Authorized Official - Middle Name:FAUSTO
Authorized Official - Last Name:BOLUMEN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:305-558-3930
Mailing Address - Street 1:344 W 65TH ST
Mailing Address - Street 2:SUITE 201
Mailing Address - City:HIALEAH
Mailing Address - State:FL
Mailing Address - Zip Code:33012-6719
Mailing Address - Country:US
Mailing Address - Phone:305-558-3930
Mailing Address - Fax:305-558-3931
Practice Address - Street 1:344 W 65TH ST
Practice Address - Street 2:SUITE 201
Practice Address - City:HIALEAH
Practice Address - State:FL
Practice Address - Zip Code:33012-6719
Practice Address - Country:US
Practice Address - Phone:305-558-3930
Practice Address - Fax:305-558-3931
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-02
Last Update Date:2012-11-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME0065418208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL374982700Medicaid