Basic Information
| Provider Information | |||||||||
| NPI: | 1508372954 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | SOUTH FLORIDA PEDIATRIC MULTI SPECIALTY | ||||||||
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| OtherOrganizationName: | SFL PEDIATRIC MULTI SPECIALTY | ||||||||
| OtherOrganizationType: | 5 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 5955 PONCE DE LEON BLVD | ||||||||
| Address2: | |||||||||
| City: | CORAL GABLES | ||||||||
| State: | FL | ||||||||
| PostalCode: | 331462423 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 5955 PONCE DE LEON BLVD | ||||||||
| Address2: | |||||||||
| City: | CORAL GABLES | ||||||||
| State: | FL | ||||||||
| PostalCode: | 331462423 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3056611515 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 12/21/2017 | ||||||||
| LastUpdateDate: | 12/21/2017 | ||||||||
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| AuthorizedOfficialLastName: | TANO | ||||||||
| AuthorizedOfficialFirstName: | ALBERTO | ||||||||
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| AuthorizedOfficialTitleorPosition: | MEDICAL DIRECTOR | ||||||||
| AuthorizedOfficialTelephone: | 3056611515 | ||||||||
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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 | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Pediatrics |
ID Information
| ID | Type | State | Issuer | Description | 372660600 | 05 | FL | MEDICAID |