Provider Demographics
NPI:1144683889
Name:ALL STAR PEDIATRICS
Entity type:Organization
Organization Name:ALL STAR PEDIATRICS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:MS
Authorized Official - First Name:KEELY
Authorized Official - Middle Name:
Authorized Official - Last Name:SAUER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:407-240-5554
Mailing Address - Street 1:14065 TOWN LOOP BLVD
Mailing Address - Street 2:SUITE 300
Mailing Address - City:ORLANDO
Mailing Address - State:FL
Mailing Address - Zip Code:32837-6199
Mailing Address - Country:US
Mailing Address - Phone:407-240-5554
Mailing Address - Fax:407-240-5543
Practice Address - Street 1:14065 TOWN LOOP BLVD
Practice Address - Street 2:SUITE 300
Practice Address - City:ORLANDO
Practice Address - State:FL
Practice Address - Zip Code:32837-6199
Practice Address - Country:US
Practice Address - Phone:407-240-5554
Practice Address - Fax:407-240-5543
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-03-31
Last Update Date:2016-03-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL0055614261QP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL0619388-00Medicaid