Healthcare Provider Details

I. General information

NPI: 1376784702
Provider Name (Legal Business Name): LITTLE PINE PEDIATRICS, PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/16/2009
Last Update Date: 02/08/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1702 S JEFFERSON ST
PERRY FL
32348-5611
US

IV. Provider business mailing address

1702 S JEFFERSON ST
PERRY FL
32348-5611
US

V. Phone/Fax

Practice location:
  • Phone: 855-577-5437
  • Fax: 850-838-2140
Mailing address:
  • Phone: 855-577-5437
  • Fax: 850-838-2140

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberOS9746
License Number StateFL
# 2
Primary TaxonomyY
Taxonomy Code261QR1300X
TaxonomyRural Health Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: DR. RONALD EMERICK
Title or Position: OWNER
Credential: D.O.
Phone: 855-577-5437