Basic Information
| Provider Information | |||||||||
| NPI: | 1770731291 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | PALM BAY PEDIATRICS | ||||||||
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| Mailing Information | |||||||||
| Address1: | 775 MALABAR RD | ||||||||
| Address2: | |||||||||
| City: | MALABAR | ||||||||
| State: | FL | ||||||||
| PostalCode: | 329503120 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3217228435 | ||||||||
| FaxNumber: | 3217228486 | ||||||||
| Practice Location | |||||||||
| Address1: | 775 MALABAR RD | ||||||||
| Address2: | |||||||||
| City: | MALABAR | ||||||||
| State: | FL | ||||||||
| PostalCode: | 329503120 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3217228435 | ||||||||
| FaxNumber: | 3217228486 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/09/2008 | ||||||||
| LastUpdateDate: | 09/09/2008 | ||||||||
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| AuthorizedOfficialLastName: | LEEDY | ||||||||
| AuthorizedOfficialFirstName: | DORIS | ||||||||
| AuthorizedOfficialMiddleName: | MARGARITA | ||||||||
| AuthorizedOfficialTitleorPosition: | OWNER/PHYSICIAN | ||||||||
| AuthorizedOfficialTelephone: | 3217228435 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | DR. | ||||||||
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| AuthorizedOfficialCredential: | M.D. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2080P0205X | ME63747 | FL | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Pediatrics | Pediatric Endocrinology | 208000000X | ME63747 | FL | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Pediatrics |
ID Information
| ID | Type | State | Issuer | Description | 632833 | 01 | FL | AETNA | OTHER | E41429 | 01 | FL | UPIN | OTHER | 3736201002 | 01 | FL | CIGNA | OTHER | 372797100 | 05 | FL | MEDICAID | 18683 | 01 | FL | BLUE CROSS BLUE SHIELD | OTHER |