Provider Demographics
NPI:1174944847
Name:PEDIATRIC SERVICES, INC.
Entity type:Organization
Organization Name:PEDIATRIC SERVICES, INC.
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:MR
Authorized Official - First Name:ALAN
Authorized Official - Middle Name:
Authorized Official - Last Name:SODERQUIST
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:305-821-1262
Mailing Address - Street 1:111 JFK DR STE B
Mailing Address - Street 2:
Mailing Address - City:ATLANTIS
Mailing Address - State:FL
Mailing Address - Zip Code:33462-6634
Mailing Address - Country:US
Mailing Address - Phone:561-227-2052
Mailing Address - Fax:561-967-8889
Practice Address - Street 1:111 JFK DR STE B
Practice Address - Street 2:
Practice Address - City:ATLANTIS
Practice Address - State:FL
Practice Address - Zip Code:33462-6634
Practice Address - Country:US
Practice Address - Phone:561-227-2052
Practice Address - Fax:561-967-8889
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-12-26
Last Update Date:2013-12-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL60081000261QH0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QH0100XAmbulatory Health Care FacilitiesClinic/CenterHealth Service
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL003412103Medicaid