Healthcare Provider Details

I. General information

NPI: 1164738191
Provider Name (Legal Business Name): VILLAGE PEDIATRICS OF ST AUGUSTINE LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/27/2010
Last Update Date: 08/27/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

319 W TOWN PL SUITE 1
ST AUGUSTINE FL
32092-3101
US

IV. Provider business mailing address

319 W TOWN PL SUITE 1
ST AUGUSTINE FL
32092-3101
US

V. Phone/Fax

Practice location:
  • Phone: 904-940-1577
  • Fax: 904-940-1916
Mailing address:
  • Phone: 904-940-1577
  • Fax: 904-940-1916

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberME93245
License Number StateFL

VIII. Authorized Official

Name: DR. PATRICIA ELVIR
Title or Position: OWNER
Credential: M.D.
Phone: 904-940-1577