Provider Demographics
NPI:1053084913
Name:LITTLE PINE PEDIATRICS PLLC
Entity Type:Organization
Organization Name:LITTLE PINE PEDIATRICS PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRACTICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:KIMBERLY
Authorized Official - Middle Name:
Authorized Official - Last Name:STROUD
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:855-577-5437
Mailing Address - Street 1:1702 S JEFFERSON ST
Mailing Address - Street 2:
Mailing Address - City:PERRY
Mailing Address - State:FL
Mailing Address - Zip Code:32348-5611
Mailing Address - Country:US
Mailing Address - Phone:855-577-5437
Mailing Address - Fax:
Practice Address - Street 1:15551 NW US HIGHWAY 441 UNIT 40
Practice Address - Street 2:
Practice Address - City:ALACHUA
Practice Address - State:FL
Practice Address - Zip Code:32615-9330
Practice Address - Country:US
Practice Address - Phone:386-518-0102
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-07-27
Last Update Date:2021-10-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral PracticeGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL001165806Medicaid