Healthcare Provider Details

I. General information

NPI: 1033114285
Provider Name (Legal Business Name): NORTH FLORIDA PEDIATRICS, PA
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/15/2005
Last Update Date: 09/08/2021
Certification Date: 09/08/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

NORTH FLORIDA PEDIATRICS, PA 1117 NW HWY 41 STE B
JASPER FL
32052
US

IV. Provider business mailing address

1859 SW NEWLAND WAY
LAKE CITY FL
32025
US

V. Phone/Fax

Practice location:
  • Phone: 386-792-3864
  • Fax: 386-792-1530
Mailing address:
  • Phone: 386-758-0003
  • Fax: 386-755-4432

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number
License Number StateFL
# 2
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberME87551
License Number StateFL
# 3
Primary TaxonomyY
Taxonomy Code261QR1300X
TaxonomyRural Health Clinic/Center
License NumberME87551
License Number StateFL

VIII. Authorized Official

Name: SAMUEL SANTELICES
Title or Position: PRESIDENT/CEO
Credential: MD
Phone: 386-758-0003