Basic Information
| Provider Information | |||||||||
| NPI: | 1053728881 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | RAYPAR INC | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | PEDIATRIC ASSOCIATES OF LAKELAND | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2140 E EDGEWOOD DR | ||||||||
| Address2: | |||||||||
| City: | LAKELAND | ||||||||
| State: | FL | ||||||||
| PostalCode: | 338033604 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8636691212 | ||||||||
| FaxNumber: | 8636666089 | ||||||||
| Practice Location | |||||||||
| Address1: | 2140 E EDGEWOOD DR | ||||||||
| Address2: | |||||||||
| City: | LAKELAND | ||||||||
| State: | FL | ||||||||
| PostalCode: | 338033604 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8636691212 | ||||||||
| FaxNumber: | 8636666089 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/14/2014 | ||||||||
| LastUpdateDate: | 07/14/2014 | ||||||||
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| AuthorizedOfficialLastName: | RAY | ||||||||
| AuthorizedOfficialFirstName: | DOROTHY | ||||||||
| AuthorizedOfficialMiddleName: | J | ||||||||
| AuthorizedOfficialTitleorPosition: | MANAGING PARTNER | ||||||||
| AuthorizedOfficialTelephone: | 8636691212 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | M.D. | ||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208000000X | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Pediatrics |
ID Information
| ID | Type | State | Issuer | Description | 002983300 | 05 | FL | MEDICAID |