Basic Information
| Provider Information | |||||||||
| NPI: | 1508071374 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | PM PEDIATRICS PA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1412 W VINE ST | ||||||||
| Address2: | |||||||||
| City: | KISSIMMEE | ||||||||
| State: | FL | ||||||||
| PostalCode: | 347414051 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4074830672 | ||||||||
| FaxNumber: | 4073485882 | ||||||||
| Practice Location | |||||||||
| Address1: | 1412 W VINE ST | ||||||||
| Address2: | |||||||||
| City: | KISSIMMEE | ||||||||
| State: | FL | ||||||||
| PostalCode: | 347414051 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4074830672 | ||||||||
| FaxNumber: | 4073485882 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/14/2007 | ||||||||
| LastUpdateDate: | 05/21/2015 | ||||||||
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| AuthorizedOfficialLastName: | IMTIAZ | ||||||||
| AuthorizedOfficialFirstName: | AZIZ | ||||||||
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| AuthorizedOfficialTitleorPosition: | PHYSICIAN | ||||||||
| AuthorizedOfficialTelephone: | 4074830672 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | MD | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208000000X | ME94323 | FL | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Pediatrics |
ID Information
| ID | Type | State | Issuer | Description | 274223300 | 05 | FL | MEDICAID |