Healthcare Provider Details

I. General information

NPI: 1558602482
Provider Name (Legal Business Name): NORTH FLORIDA PEDIATRICS, PA
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/01/2013
Last Update Date: 09/08/2021
Certification Date: 09/08/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

NORTH FLORIDA PEDIATRICS, PA 1101 OHIO AVENUE SOUTH
LIVE OAK FL
32064
US

IV. Provider business mailing address

1859 SW NEWLAND WAY
LAKE CITY FL
32025-6966
US

V. Phone/Fax

Practice location:
  • Phone: 386-339-1060
  • Fax: 386-339-1067
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 State
# 2
Primary TaxonomyN
Taxonomy Code2080A0000X
TaxonomyPediatric Adolescent Medicine Physician
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code261QR1300X
TaxonomyRural Health Clinic/Center
License Number
License Number State

VIII. Authorized Official

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