Provider Demographics
NPI:1932441144
Name:MT CARMEL PEDIATRICS LLC
Entity type:Organization
Organization Name:MT CARMEL PEDIATRICS LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MGRM
Authorized Official - Prefix:DR
Authorized Official - First Name:JEANNE
Authorized Official - Middle Name:
Authorized Official - Last Name:GO
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:561-600-9015
Mailing Address - Street 1:200 KNUTH RD
Mailing Address - Street 2:SUITE 106
Mailing Address - City:BOYNTON BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:33436-4629
Mailing Address - Country:US
Mailing Address - Phone:561-600-9015
Mailing Address - Fax:561-600-9016
Practice Address - Street 1:200 KNUTH RD
Practice Address - Street 2:SUITE 106
Practice Address - City:BOYNTON BEACH
Practice Address - State:FL
Practice Address - Zip Code:33436-4629
Practice Address - Country:US
Practice Address - Phone:561-600-9015
Practice Address - Fax:561-600-9016
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-03-26
Last Update Date:2013-10-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME0041663208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL067795700Medicaid
FL265620500Medicaid