MEDICARE: NORTH FLORIDA PEDIATRICS, PA.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	208000000X	Pediatrics Physician	ME87551	FL
2	2080A0000X	Pediatric Adolescent Medicine Physician	ME87551	FL
3	261QR1300X	Rural Health Clinic/Center	ME87551	FL

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1376548602
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	NORTH FLORIDA PEDIATRICS, PA.

Provider Business Mailing Address
First Line	:	1859 SW NEWLAND WAY
Second Line	:
City	:	LAKE CITY
State	:	FL
Zip	:	32025-6966
Country	:	US
Telephone Number	:	386-758-0003
Fax Number	:	386-755-4432

Provider Business Practice Location Address
First Line	:	NORTH FLORIDA PEDIATRICS PA .
Second Line	:	1859 SW NEWLAND WAY
City	:	LAKE CITY
State	:	FL
Zip	:	32025
Country	:	US
Telephone Number	:	386-758-0003
Fax Number	:	386-755-4432

Authorized Official
Title or Position	:	PRESIDENT/ CEO
Name	:	SAMUEL SANTELICES
Credential	:	MD.
Telephone Number	:	386-758-0003

Provider Enumeration Date	:	06/14/2005
Last Update Date	:	09/08/2021

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Directions to “NORTH FLORIDA PEDIATRICS, PA. ” Practice Location

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