Provider Demographics
NPI:1720619422
Name:PEDIATRIC ASSOCIATES OF NORTHEAST FLORIDA, LLC
Entity type:Organization
Organization Name:PEDIATRIC ASSOCIATES OF NORTHEAST FLORIDA, LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:PATRICIA
Authorized Official - Middle Name:
Authorized Official - Last Name:CORSIATTO
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:954-965-7331
Mailing Address - Street 1:900 S PINE ISLAND RD STE 800
Mailing Address - Street 2:
Mailing Address - City:PLANTATION
Mailing Address - State:FL
Mailing Address - Zip Code:33324-3923
Mailing Address - Country:US
Mailing Address - Phone:954-967-6400
Mailing Address - Fax:954-965-7339
Practice Address - Street 1:155 BARTRAM MARKET DR STE 120
Practice Address - Street 2:
Practice Address - City:ST JOHNS
Practice Address - State:FL
Practice Address - Zip Code:32259-4582
Practice Address - Country:US
Practice Address - Phone:904-650-2193
Practice Address - Fax:904-201-6350
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-01-31
Last Update Date:2021-05-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL011962603Medicaid