1336818632 NPI number — NORTH FLORIDA PEDIATRICS PA

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1336818632 NPI number — NORTH FLORIDA PEDIATRICS PA

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
NORTH FLORIDA PEDIATRICS PA
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1336818632
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
09/09/2021
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
NORTH FLORIDA PEDIATRICS, PA
Provider Second Line Business Mailing Address:
1859 SW NEWLAND WAY
Provider Business Mailing Address City Name:
LAKE CITY
Provider Business Mailing Address State Name:
FL
Provider Business Mailing Address Postal Code:
32025
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
386-758-0003
Provider Business Mailing Address Fax Number:
386-755-4432

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
149 NE. 241ST STREET
Provider Second Line Business Practice Location Address:
STE A
Provider Business Practice Location Address City Name:
CROSS CITY
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
32628
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
352-498-3337
Provider Business Practice Location Address Fax Number:
352-498-3773
Provider Enumeration Date:
09/09/2021

Additional Information

Authorized Official

Authorized Official Last Name:
SANTELICES
Authorized Official First Name:
SAMUEL
Authorized Official Middle Name:
Authorized Official Title or Position:
PRESIDENT / CEO
Authorized Official Telephone Number:
386-758-0003

Provider Taxonomy Codes

  • Taxonomy code: 208000000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 019432301 , issued by the state of ( FL ) . This identifiers is of the category "MEDICAID".




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