Provider Demographics
NPI:1033114285
Name:NORTH FLORIDA PEDIATRICS, PA
Entity Type:Organization
Organization Name:NORTH FLORIDA PEDIATRICS, PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT/CEO
Authorized Official - Prefix:
Authorized Official - First Name:SAMUEL
Authorized Official - Middle Name:
Authorized Official - Last Name:SANTELICES
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:386-758-0003
Mailing Address - Street 1:1859 SW NEWLAND WAY
Mailing Address - Street 2:
Mailing Address - City:LAKE CITY
Mailing Address - State:FL
Mailing Address - Zip Code:32025
Mailing Address - Country:US
Mailing Address - Phone:386-758-0003
Mailing Address - Fax:386-755-4432
Practice Address - Street 1:NORTH FLORIDA PEDIATRICS, PA
Practice Address - Street 2:1117 NW HWY 41 STE B
Practice Address - City:JASPER
Practice Address - State:FL
Practice Address - Zip Code:32052
Practice Address - Country:US
Practice Address - Phone:386-792-3864
Practice Address - Fax:386-792-1530
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:NORTH FLORIDA PEDIATRICS
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2005-06-15
Last Update Date:2021-09-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL208000000X, 2080A0000X
FLME87551208000000X, 261QR1300X, 261QR1300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261QR1300XAmbulatory Health Care FacilitiesClinic/CenterRural HealthGroup - Single Specialty
No208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Single Specialty
No2080A0000XAllopathic & Osteopathic PhysiciansPediatricsAdolescent MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL001534800Medicaid