Healthcare Provider Details

I. General information

NPI: 1396805115
Provider Name (Legal Business Name): PEDIATRIC AND INTERNAL MEDICINE SPECIALISTS INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/11/2006
Last Update Date: 02/13/2025
Certification Date: 02/13/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1990 N PROSPECT AVE
LECANTO FL
34461-9792
US

IV. Provider business mailing address

PO BOX 2066
LECANTO FL
34460-2066
US

V. Phone/Fax

Practice location:
  • Phone: 352-527-6888
  • Fax: 352-527-8818
Mailing address:
  • Phone: 352-527-6888
  • Fax: 352-527-8818

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code246RM2200X
TaxonomyMedical Laboratory Technician
License Number
License Number State
# 5
Primary TaxonomyN
Taxonomy Code261Q00000X
TaxonomyClinic/Center
License Number10D1050573
License Number StateFL
# 6
Primary TaxonomyN
Taxonomy Code261QP2000X
TaxonomyPhysical Therapy Clinic/Center
License Number
License Number State
# 7
Primary TaxonomyN
Taxonomy Code261QS1200X
TaxonomySleep Disorder Diagnostic Clinic/Center
License Number
License Number State
# 8
Primary TaxonomyN
Taxonomy Code332B00000X
TaxonomyDurable Medical Equipment & Medical Supplies
License Number
License Number State

VIII. Authorized Official

Name: DR. DACELIN ST. MARTIN
Title or Position: MEDICAL DIRECTOR/OWNER
Credential: MD
Phone: 352-527-6888