Healthcare Provider Details

I. General information

NPI: 1548758428
Provider Name (Legal Business Name): NORTH FLORIDA PEDIATRICS PA
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/26/2018
Last Update Date: 09/08/2021
Certification Date: 09/08/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

417 EAST CALL STREET
STARKE FL
32091
US

IV. Provider business mailing address

1859 S.W. NEWLAND WAY
LAKE CITY FL
32025
US

V. Phone/Fax

Practice location:
  • Phone: 904-368-0368
  • Fax: 904-317-4949
Mailing address:
  • Phone: 386-758-0003
  • Fax: 386-755-4432

VI. Provider taxonomy

Scope of Practice (Provider specialty)

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

VIII. Authorized Official

Name: SAMUEL SANTELICES
Title or Position: PRESIDENT/CEO
Credential:
Phone: 386-758-0003