Basic Information
| Provider Information | |||||||||
| NPI: | 1972554962 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | PEDIATRIX MEDICAL GROUP | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3001 E PRESIDENT GEORGE BUSH HWY | ||||||||
| Address2: | SUITE 250 | ||||||||
| City: | RICHARDSON | ||||||||
| State: | TX | ||||||||
| PostalCode: | 750823542 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9724375099 | ||||||||
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| Practice Location | |||||||||
| Address1: | 3001 E PRESIDENT GEORGE BUSH HWY | ||||||||
| Address2: | SUITE 250 | ||||||||
| City: | RICHARDSON | ||||||||
| State: | TX | ||||||||
| PostalCode: | 750823542 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9724375099 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 05/13/2006 | ||||||||
| LastUpdateDate: | 03/03/2016 | ||||||||
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| AuthorizedOfficialLastName: | FLAVIN | ||||||||
| AuthorizedOfficialFirstName: | NANCY | ||||||||
| AuthorizedOfficialMiddleName: | ELLEN | ||||||||
| AuthorizedOfficialTitleorPosition: | NEONATAL NURSE PRACTITONER | ||||||||
| AuthorizedOfficialTelephone: | 9724375099 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MS. | ||||||||
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| AuthorizedOfficialCredential: | RNC, MSN, NNP | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LC0200X | 676602 | TX | Y | 193400000X SINGLE SPECIALTY GROUP | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Critical Care Medicine |
No ID Information.