Basic Information
| Provider Information | |||||||||
| NPI: | 1528003365 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | THE PEDIATRIC CENTER | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | |||||||||
| OtherOrganizationName: | THE PEDIATRIC CENTER | ||||||||
| OtherOrganizationType: | 5 | ||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | |||||||||
| Mailing Information | |||||||||
| Address1: | 1447 MEDICAL PARK BLVD | ||||||||
| Address2: | SUITE 402 | ||||||||
| City: | WELLINGTON | ||||||||
| State: | FL | ||||||||
| PostalCode: | 33414 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5617902600 | ||||||||
| FaxNumber: | 5617901535 | ||||||||
| Practice Location | |||||||||
| Address1: | 1447 MEDICAL PARK BLVD. | ||||||||
| Address2: | SUITE 402 | ||||||||
| City: | WELLINGTON | ||||||||
| State: | FL | ||||||||
| PostalCode: | 33414 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5617902600 | ||||||||
| FaxNumber: | 5617982857 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/17/2006 | ||||||||
| LastUpdateDate: | 12/30/2015 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | KHOSRAVANI | ||||||||
| AuthorizedOfficialFirstName: | ALI | ||||||||
| AuthorizedOfficialMiddleName: | I | ||||||||
| AuthorizedOfficialTitleorPosition: | SEC-TREASURY | ||||||||
| AuthorizedOfficialTelephone: | 5617902600 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | M.D. | ||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208000000X | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Pediatrics |
ID Information
| ID | Type | State | Issuer | Description | 205500 | 01 | FL | AMERIGROUP | OTHER | 176316 | 01 | FL | HEALTHEASE | OTHER | 378772901 | 05 | FL | MEDICAID | 378772900 | 05 | FL | MEDICAID |