Basic Information
| Provider Information | |||||||||
| NPI: | 1912345497 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | PEDIATRIC ASSOCIATES OF TAMPA BAY, LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 900 S PINE ISLAND RD | ||||||||
| Address2: | 800 | ||||||||
| City: | PLANTATION | ||||||||
| State: | FL | ||||||||
| PostalCode: | 333243920 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9549676400 | ||||||||
| FaxNumber: | 9549657339 | ||||||||
| Practice Location | |||||||||
| Address1: | 10710 STATE ROAD 54 STE 108 | ||||||||
| Address2: | |||||||||
| City: | TRINITY | ||||||||
| State: | FL | ||||||||
| PostalCode: | 346552263 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7273764040 | ||||||||
| FaxNumber: | 7273768824 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/06/2013 | ||||||||
| LastUpdateDate: | 08/25/2020 | ||||||||
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| AuthorizedOfficialLastName: | SHULMAN | ||||||||
| AuthorizedOfficialFirstName: | PETER | ||||||||
| AuthorizedOfficialMiddleName: | J | ||||||||
| AuthorizedOfficialTitleorPosition: | CEO | ||||||||
| AuthorizedOfficialTelephone: | 9549657322 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | PEDIATRIC ASSOCIATES HOLDING COMPANY | ||||||||
| AuthorizedOfficialNamePrefix: | DR. | ||||||||
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| AuthorizedOfficialCredential: | MD | ||||||||
| NPICertificationDate: | 08/25/2020 | ||||||||
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 | 008927601 | 05 | FL | MEDICAID |