Provider Demographics
NPI:1780816827
Name:FLORIDA STATE UNIVERSITY, PEDIATRIC RESIDENCY AT SACRED HEART HOSPITAL
Entity type:Organization
Organization Name:FLORIDA STATE UNIVERSITY, PEDIATRIC RESIDENCY AT SACRED HEART HOSPITAL
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:RESIDENCY COORDINATOR
Authorized Official - Prefix:
Authorized Official - First Name:IRIS
Authorized Official - Middle Name:
Authorized Official - Last Name:FITTS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:850-416-7658
Mailing Address - Street 1:5153 N 9TH AVE
Mailing Address - Street 2:
Mailing Address - City:PENSACOLA
Mailing Address - State:FL
Mailing Address - Zip Code:32504-8785
Mailing Address - Country:US
Mailing Address - Phone:818-448-2111
Mailing Address - Fax:850-416-7677
Practice Address - Street 1:5153 N 9TH AVE
Practice Address - Street 2:
Practice Address - City:PENSACOLA
Practice Address - State:FL
Practice Address - Zip Code:32504-8785
Practice Address - Country:US
Practice Address - Phone:818-448-2111
Practice Address - Fax:850-416-7677
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-08-21
Last Update Date:2009-08-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLTRN13578208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Single Specialty