Healthcare Provider Details

I. General information

NPI: 1801649686
Provider Name (Legal Business Name): PENSACOLA PEDIATRICS, PA
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/10/2024
Last Update Date: 04/10/2024
Certification Date: 04/10/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5868 CREEK STATION DR
PENSACOLA FL
32504-8627
US

IV. Provider business mailing address

4951 GRANDE DR
PENSACOLA FL
32504-8965
US

V. Phone/Fax

Practice location:
  • Phone: 850-473-0100
  • Fax: 850-473-0500
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