Provider Demographics
NPI:1528438694
Name:FLORIDA PEDIATRIC GROUP PA
Entity type:Organization
Organization Name:FLORIDA PEDIATRIC GROUP PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:MR
Authorized Official - First Name:MAGED
Authorized Official - Middle Name:
Authorized Official - Last Name:FARID
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:321-752-5210
Mailing Address - Street 1:250 S WICKHAM RD
Mailing Address - Street 2:
Mailing Address - City:WEST MELBOURNE
Mailing Address - State:FL
Mailing Address - Zip Code:32904-1134
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:250 S WICKHAM RD
Practice Address - Street 2:
Practice Address - City:WEST MELBOURNE
Practice Address - State:FL
Practice Address - Zip Code:32904-1134
Practice Address - Country:US
Practice Address - Phone:321-752-5210
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-10-01
Last Update Date:2015-10-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Single Specialty