Healthcare Provider Details

I. General information

NPI: 1013680651
Provider Name (Legal Business Name): PENSACOLA PEDIATRICS PA
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/29/2021
Last Update Date: 07/29/2021
Certification Date: 07/29/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1368 COUNTRY CLUB RD
GULF BREEZE FL
32563-3471
US

IV. Provider business mailing address

4951 GRANDE DR
PENSACOLA FL
32504-8965
US

V. Phone/Fax

Practice location:
  • Phone: 850-934-9876
  • Fax: 850-916-0736
Mailing address:
  • Phone: 850-473-0100
  • Fax: 850-473-0500

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number
License Number State

VIII. Authorized Official

Name: PETER HECKATHORN
Title or Position: ADMINISTRATOR
Credential:
Phone: 850-473-0100