Healthcare Provider Details

I. General information

NPI: 1053598292
Provider Name (Legal Business Name): ANCIENT CITY PEDIATRICS
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/30/2008
Last Update Date: 09/02/2025
Certification Date: 10/23/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1301 PLANTATION ISLAND DR S STE 104
SAINT AUGUSTINE FL
32080-3108
US

IV. Provider business mailing address

1301 PLANTATION ISLAND DR S STE 104
SAINT AUGUSTINE FL
32080-3108
US

V. Phone/Fax

Practice location:
  • Phone: 904-461-1560
  • Fax: 904-461-4304
Mailing address:
  • Phone: 904-461-1560
  • Fax: 904-461-4304

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number
License Number State

VIII. Authorized Official

Name: ADRIENNE MCCOY
Title or Position: OFFICE MANAGER
Credential:
Phone: 904-461-1560