Basic Information
| Provider Information | |||||||||
| NPI: | 1316385164 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | RAINBOW PEDIATRIC CENTER | ||||||||
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| Mailing Information | |||||||||
| Address1: | 4788 HODGES BLVD | ||||||||
| Address2: | SUITE B-108 | ||||||||
| City: | JACKSONVILLE | ||||||||
| State: | FL | ||||||||
| PostalCode: | 322247222 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9042239100 | ||||||||
| FaxNumber: | 9042239282 | ||||||||
| Practice Location | |||||||||
| Address1: | 4788 HODGES BLVD | ||||||||
| Address2: | SUITE B-108 | ||||||||
| City: | JACKSONVILLE | ||||||||
| State: | FL | ||||||||
| PostalCode: | 322247222 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9042239100 | ||||||||
| FaxNumber: | 9042239282 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/13/2013 | ||||||||
| LastUpdateDate: | 09/16/2014 | ||||||||
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| AuthorizedOfficialLastName: | REDDY | ||||||||
| AuthorizedOfficialFirstName: | PRASANTHI | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | OWNER/ DOCTOR | ||||||||
| AuthorizedOfficialTelephone: | 9042239100 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | DR. | ||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | MD | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2080A0000X | ME91195 | FL | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Pediatrics | Adolescent Medicine |
ID Information
| ID | Type | State | Issuer | Description | 008830500 | 05 | FL | MEDICAID |