Basic Information
| Provider Information | |||||||||
| NPI: | 1508241480 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | CHILDREN'S HEMATOLOGY & ONCOLOGY ASSOCIATES | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | A DIVISON OF KIDZ MEDICAL SERVICES, INC | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 5955 PONCE DE LEON BLVD | ||||||||
| Address2: | |||||||||
| City: | CORAL GABLES | ||||||||
| State: | FL | ||||||||
| PostalCode: | 33146 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3056611515 | ||||||||
| FaxNumber: | 3056635948 | ||||||||
| Practice Location | |||||||||
| Address1: | 9980 CENTRAL PARK BLVD. | ||||||||
| Address2: | SUITE 206 | ||||||||
| City: | BOCA RATON | ||||||||
| State: | FL | ||||||||
| PostalCode: | 33428 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5618446363 | ||||||||
| FaxNumber: | 5618446391 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/21/2015 | ||||||||
| LastUpdateDate: | 07/21/2015 | ||||||||
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| AuthorizedOfficialLastName: | PEREZ | ||||||||
| AuthorizedOfficialFirstName: | JORGE | ||||||||
| AuthorizedOfficialMiddleName: | E | ||||||||
| AuthorizedOfficialTitleorPosition: | MEDICAL DIRECTOR | ||||||||
| AuthorizedOfficialTelephone: | 3056611515 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MR. | ||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | MD | ||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2080P0207X | FL | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Pediatrics | Pediatric Hematology-Oncology |
ID Information
| ID | Type | State | Issuer | Description | 257-829-800 | 05 | FL | MEDICAID |