Basic Information
| Provider Information | |||||||||
| NPI: | 1336496629 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | DR. ROSIE'S PEDIATRICS | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | |||||||||
| OtherOrganizationName: | KID'S PLACE PEDIATRICS, P.A. | ||||||||
| OtherOrganizationType: | 3 | ||||||||
| OtherLastName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | 466 SW PORT SAINT LUCIE BLVD., SUITE 116 | ||||||||
| Address2: | |||||||||
| City: | PORT SAINT LUCIE | ||||||||
| State: | FL | ||||||||
| PostalCode: | 349532091 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7723417433 | ||||||||
| FaxNumber: | 7722374622 | ||||||||
| Practice Location | |||||||||
| Address1: | 466 SW PORT SAINT LUCIE BLVD., SUITE 116 | ||||||||
| Address2: | |||||||||
| City: | PORT SAINT LUCIE | ||||||||
| State: | FL | ||||||||
| PostalCode: | 349532091 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7723417433 | ||||||||
| FaxNumber: | 7722374622 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/06/2012 | ||||||||
| LastUpdateDate: | 12/22/2021 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | CORREA | ||||||||
| AuthorizedOfficialFirstName: | ROSARIO | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | OWNER | ||||||||
| AuthorizedOfficialTelephone: | 7723417433 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | APRN | ||||||||
| NPICertificationDate: | 12/22/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208000000X | ME91787 | FL | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Pediatrics |
ID Information
| ID | Type | State | Issuer | Description | 271863400 | 05 | FL | MEDICAID | U4547A | 01 | FL | MEDICARE | OTHER |