Provider Demographics
NPI:1548758428
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:
Authorized Official - Phone:386-758-0003
Mailing Address - Street 1:1859 S.W. 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 1:417 EAST CALL STREET
Practice Address - Street 2:
Practice Address - City:STARKE
Practice Address - State:FL
Practice Address - Zip Code:32091
Practice Address - Country:US
Practice Address - Phone:904-368-0368
Practice Address - Fax:904-317-4949
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:NORTH FLORIDA PEDIATRICS PA
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2018-04-26
Last Update Date:2021-09-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261QR1300XAmbulatory Health Care FacilitiesClinic/CenterRural Health
No208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL101707400Medicaid