=====================================================
General NPI Number Information
=====================================================
NPI Number | 1174518179
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | ST AUGUSTINE ADULT & PEDIATRIC MEDICINE PA
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/15/2005
-----------------------------------------------------
Last Update Date | 11/10/2010
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 67 S DIXIE HWY
-----------------------------------------------------
City | ST AUGUSTINE
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 32084-0317
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 904-827-0032
-----------------------------------------------------
Fax | 904-827-0985
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 67 S DIXIE HWY
-----------------------------------------------------
City | ST AUGUSTINE
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 32084-0317
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 904-827-0032
-----------------------------------------------------
Fax | 904-827-0985
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | MD
-----------------------------------------------------
Name | VANDANA Y BHIDE
-----------------------------------------------------
Credential | MD
-----------------------------------------------------
Telephone | 904-827-0032
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207R00000X
-----------------------------------------------------
Taxonomy Name | Internal Medicine Physician
-----------------------------------------------------
License Number | ME73431
-----------------------------------------------------
License Number State | FL
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 208000000X
-----------------------------------------------------
Taxonomy Name | Pediatrics Physician
-----------------------------------------------------
License Number | ME73431
-----------------------------------------------------
License Number State | FL
-----------------------------------------------------