Provider Demographics
NPI:1164738191
Name:VILLAGE PEDIATRICS OF ST AUGUSTINE LLC
Entity Type:Organization
Organization Name:VILLAGE PEDIATRICS OF ST AUGUSTINE LLC
Other - Org Name:VILLAGE PEDIATRICS LLC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:PATRICIA
Authorized Official - Middle Name:
Authorized Official - Last Name:ELVIR
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:904-940-1577
Mailing Address - Street 1:319 W TOWN PL
Mailing Address - Street 2:SUITE 1
Mailing Address - City:ST AUGUSTINE
Mailing Address - State:FL
Mailing Address - Zip Code:32092-3101
Mailing Address - Country:US
Mailing Address - Phone:904-940-1577
Mailing Address - Fax:904-940-1916
Practice Address - Street 1:319 W TOWN PL
Practice Address - Street 2:SUITE 1
Practice Address - City:ST AUGUSTINE
Practice Address - State:FL
Practice Address - Zip Code:32092-3101
Practice Address - Country:US
Practice Address - Phone:904-940-1577
Practice Address - Fax:904-940-1916
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-08-27
Last Update Date:2010-08-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME93245208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Single Specialty