Provider Demographics
NPI:1255004586
Name:PENSACOLA PEDIATRICS, PA
Entity Type:Organization
Organization Name:PENSACOLA PEDIATRICS, PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:PETER
Authorized Official - Middle Name:
Authorized Official - Last Name:HECKATHORN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:850-473-0100
Mailing Address - Street 1:4951 GRANDE DR
Mailing Address - Street 2:
Mailing Address - City:PENSACOLA
Mailing Address - State:FL
Mailing Address - Zip Code:32504-8965
Mailing Address - Country:US
Mailing Address - Phone:850-473-0100
Mailing Address - Fax:850-473-0500
Practice Address - Street 1:9301 BEATRICE DR
Practice Address - Street 2:
Practice Address - City:PENSACOLA
Practice Address - State:FL
Practice Address - Zip Code:32514-5867
Practice Address - Country:US
Practice Address - Phone:850-476-7555
Practice Address - Fax:850-466-3777
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-08-02
Last Update Date:2021-08-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL063018702Medicaid