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General NPI Number Information
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NPI Number | 1053598292
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Entity Type | Organization
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Legal Business Name | ANCIENT CITY PEDIATRICS
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Dates
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Enumeration Date | 01/30/2008
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Last Update Date | 09/02/2025
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Provider Practice Location Address
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Address Line | 1301 PLANTATION ISLAND DR S STE 104
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City | SAINT AUGUSTINE
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State | FL
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Zip | 32080-3108
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Country | US
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Telephone | 904-461-1560
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Fax | 904-461-4304
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Provider Business Mailing Address
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Address Line | 1301 PLANTATION ISLAND DR S STE 104
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City | SAINT AUGUSTINE
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State | FL
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Zip | 32080-3108
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Country | US
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Telephone | 904-461-1560
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Fax | 904-461-4304
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Authorized Official
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Title or Position | OFFICE MANAGER
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Name | ADRIENNE MCCOY
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Credential |
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Telephone | 904-461-1560
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 208000000X
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Taxonomy Name | Pediatrics Physician
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License Number |
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License Number State |
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