Provider Demographics
NPI:1396415915
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 2:1101 OHIO AVENUE SOUTH
Practice Address - City:LIVE OAK
Practice Address - State:FL
Practice Address - Zip Code:32064
Practice Address - Country:US
Practice Address - Phone:386-339-1060
Practice Address - Fax:386-339-1067
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:NORTH FLORIDA PEDIATRICS, PA.
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2021-09-15
Last Update Date:2021-09-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL015048101Medicaid