Provider Demographics
NPI:1447553805
Name:FLORIDA PEDIATRIC ASSOCIATES, LLC
Entity type:Organization
Organization Name:FLORIDA PEDIATRIC ASSOCIATES, LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CREDENTIALING MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:SHEILA
Authorized Official - Middle Name:A
Authorized Official - Last Name:TATHAM
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:727-456-4250
Mailing Address - Street 1:1033 DR MARTIN LUTHER KING JR ST N
Mailing Address - Street 2:SUITE 108
Mailing Address - City:ST PETERSBURG
Mailing Address - State:FL
Mailing Address - Zip Code:33701-1547
Mailing Address - Country:US
Mailing Address - Phone:727-456-3288
Mailing Address - Fax:727-456-3289
Practice Address - Street 1:1781 PARK CENTER DR
Practice Address - Street 2:SUITE 220
Practice Address - City:ORLANDO
Practice Address - State:FL
Practice Address - Zip Code:32835-6254
Practice Address - Country:US
Practice Address - Phone:407-398-7730
Practice Address - Fax:407-398-7740
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-12-07
Last Update Date:2010-12-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL38313OtherMEDICARE PTAN