Healthcare Provider Details

I. General information

NPI: 1780816827
Provider Name (Legal Business Name): FLORIDA STATE UNIVERSITY, PEDIATRIC RESIDENCY AT SACRED HEART HOSPITAL
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/21/2009
Last Update Date: 08/21/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5153 N 9TH AVE
PENSACOLA FL
32504-8785
US

IV. Provider business mailing address

5153 N 9TH AVE
PENSACOLA FL
32504-8785
US

V. Phone/Fax

Practice location:
  • Phone: 818-448-2111
  • Fax: 850-416-7677
Mailing address:
  • Phone: 818-448-2111
  • Fax: 850-416-7677

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberTRN13578
License Number StateFL

VIII. Authorized Official

Name: IRIS FITTS
Title or Position: RESIDENCY COORDINATOR
Credential:
Phone: 850-416-7658