Basic Information
| Provider Information | |||||||||
| NPI: | 1366676033 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | KIDZ MEDICAL SERVICES | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | KIDZ SURGICAL CENTER | ||||||||
| OtherOrganizationType: | 5 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 5955 PONCE DE LEON BLVD | ||||||||
| Address2: | |||||||||
| City: | CORAL GABLES | ||||||||
| State: | FL | ||||||||
| PostalCode: | 331462423 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3056611515 | ||||||||
| FaxNumber: | 3056623723 | ||||||||
| Practice Location | |||||||||
| Address1: | 5955 PONCE DE LEON BLVD | ||||||||
| Address2: | |||||||||
| City: | CORAL GABLES | ||||||||
| State: | FL | ||||||||
| PostalCode: | 331462423 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3056611515 | ||||||||
| FaxNumber: | 3056623723 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/11/2009 | ||||||||
| LastUpdateDate: | 05/11/2009 | ||||||||
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| AuthorizedOfficialLastName: | PEREZ | ||||||||
| AuthorizedOfficialFirstName: | JORGE | ||||||||
| AuthorizedOfficialMiddleName: | E. | ||||||||
| AuthorizedOfficialTitleorPosition: | PARTNERS | ||||||||
| AuthorizedOfficialTelephone: | 3056611515 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | MD | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2086S0120X | ME 53246 | FL | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Surgery | Pediatric Surgery |
ID Information
| ID | Type | State | Issuer | Description | 372 652 500 | 05 | FL | MEDICAID |