Basic Information
| Provider Information | |||||||||
| NPI: | 1720179120 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | PALM HARBOR PEDIATRIC URGENT CARE CENTER PA | ||||||||
| LastName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 23863 | ||||||||
| Address2: | |||||||||
| City: | TAMPA | ||||||||
| State: | FL | ||||||||
| PostalCode: | 336233863 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7278232188 | ||||||||
| FaxNumber: | 7278239502 | ||||||||
| Practice Location | |||||||||
| Address1: | 36458 US HIGHWAY 19 N | ||||||||
| Address2: | |||||||||
| City: | PALM HARBOR | ||||||||
| State: | FL | ||||||||
| PostalCode: | 346841330 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7277875439 | ||||||||
| FaxNumber: | 7277876221 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/28/2006 | ||||||||
| LastUpdateDate: | 12/03/2008 | ||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | MARAMARA | ||||||||
| AuthorizedOfficialFirstName: | LUIS | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | PROVIDER/OWNER | ||||||||
| AuthorizedOfficialTelephone: | 7277875439 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | MD | ||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QU0200X | Y | Ambulatory Health Care Facilities | Clinic/Center | Urgent Care |
ID Information
| ID | Type | State | Issuer | Description | 282538 | 01 | AVMED | OTHER | B903Q | 01 | FL | BCBS | OTHER | 196501 | 01 | FL | WELLCARE | OTHER | 220597 | 01 | AMERIGROUP | OTHER | 271730100 | 05 | FL | MEDICAID |