Provider Demographics
NPI:1629286299
Name:ST. AUGUSTINE PEDIATRIC ASSOCIATES, PA
Entity Type:Organization
Organization Name:ST. AUGUSTINE PEDIATRIC ASSOCIATES, PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:
Authorized Official - Last Name:SOBERANO
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:904-824-5437
Mailing Address - Street 1:1301 PLANTATION ISLAND DR S
Mailing Address - Street 2:SUITE 106B
Mailing Address - City:ST AUGUSTINE
Mailing Address - State:FL
Mailing Address - Zip Code:32080-3108
Mailing Address - Country:US
Mailing Address - Phone:904-461-8906
Mailing Address - Fax:904-461-7575
Practice Address - Street 1:1301 PLANTATION ISLAND DR S
Practice Address - Street 2:SUITE 106B
Practice Address - City:ST AUGUSTINE
Practice Address - State:FL
Practice Address - Zip Code:32080-3108
Practice Address - Country:US
Practice Address - Phone:904-461-8906
Practice Address - Fax:904-461-7575
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-18
Last Update Date:2015-08-17
Deactivation Date:2011-11-22
Deactivation Code:
Reactivation Date:2015-08-17
Provider Licenses
StateLicense IDTaxonomies
FLME78696208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Single Specialty