North Florida Pediatrics, PA
Organization Active NPI Rural Health Clinic/Center · Jasper, FL
NPI 1033114285 · NPPES record last updated Sep 8, 2021
Key facts
- NPI
- 1033114285
- Entity type
- Organization (NPI type 2)
- Primary specialty
- Rural Health Clinic/Center 261QR1300X
- License
- ME87551 (FL)
- Legal business name
- NORTH FLORIDA PEDIATRICS, PA
- Practice address
- North Florida Pediatrics, PA
1117 NW Hwy 41 Ste B
Jasper, FL 32052 - Phone
- (386) 792-3864
- Fax
- (386) 792-1530
- NPI assigned
- Jun 15, 2005
- Organization subpart
- Yes
- Parent organization (as reported)
- NORTH FLORIDA PEDIATRICS
Authorized official
- Name
- Samuel Santelices, MD
- Title
- President/Ceo
- Phone
- (386) 758-0003
Owners & managing parties with NPI records 1
Owned or controlled facilities with NPI records 2
Other NPIs on the same Medicare enrollment 2
Other NPIs with the same Medicare PAC ID 5
Corporate family (same tax ID) 16
Practitioners 24
-
Jessica Maria Andrade, APRN FNP-BC
-
Amy Elizabeth Beach, FNP-C
-
Caitlin Christine Charette-Zalewski, MS, CPNP
-
Jourdan Ashley Clum, ARNP
-
Amy Danielle Dobberfuhl, APRN CPNP-PC
-
Jasmine Green, FNP
-
Maria Anne Harmon, ARNP
-
Leidys Lopez, NP-C
-
Bridgette Renee Loska, APRN, FNP-C
-
Maria Martinez-Ramos, M.D.
-
Lourdes A Mosley, PA
-
Martinique Rummel, DNP
-
Maria D. Smith, M.D.
-
Megan Fultz Smith, ARNP
-
Ronald Stephens, APRN
-
Kara Trzasko, PA-C
-
Neda Ruth Watanabe, PA-C
-
Amna Zarar, M.D
-
Jasmine Loving Dawson, FNP-C
Medicare participation
- Medicare fee-for-service enrollment
- Enrolled (2 enrollments) in FL
Rural health clinic certification: CCN 108906
- Legal name
- NORTH FLORIDA PEDIATRICS, PA
- Certification status
- Active
- Provider type (POS)
- Rural health clinic
- Participating since
- Jul 20, 1998
- Last certification
- Dec 27, 2023
- Ownership / control type
- 1A
- Organization structure
- Corporation · Proprietary
- Incorporated
- Nov 28, 1995 in FL
- Enrollment address
- 1117 US Highway 41 NW
Suite B
Jasper, FL 32052-5856
All disclosed owners & managing parties 1
| Name | Role | Since | Share |
|---|---|---|---|
| Samuel Santelices |
5% Or Greater Direct Ownership Interest |
Jan 1, 2010 | 100% |
| Corporate Officer |
Jan 1, 2010 | 100% | |
| W-2 Managing Employee | Jan 1, 2025 |
All facility ownership & control disclosures 2
| Facility | Type | Role | Since |
|---|---|---|---|
| Acute Care Pediatrics,PA |
Rural health clinic | 5% Or Greater Direct Ownership Interest | May 1, 2024 |
| Acute Care Pediatrics of Palm Coast PA |
Rural health clinic | 5% Or Greater Direct Ownership Interest (100%) | May 1, 2024 |
Medicare enrollment records
| Enrollment ID | State | Provider type | PAC ID | Details |
|---|---|---|---|---|
| O20030324000027 | FL | Part a Provider - Rural Health Clinic | 8729997929 | Practice locations: Jasper, FL |
| O20040602000593 | FL | Part B Supplier - Clinic/Group Practice | 8729997929 |
Receives reassigned benefits from 4 practitioners 2 other NPIs on this enrollment This NPI is an additional NPI on the enrollment Practice locations: Cross City, FL; Jasper, FL; Lake City, FL; Live Oak, FL |
National Provider Directory
- Tax ID family
- North Florida Pediatrics PA
- Part of
- North Florida Pediatrics PA
Locations
1117 US Highway 41 NW
#B
Jasper, FL 32052
Phone (386) 792-3864
1101 Ohio Ave S
Live Oak, FL 32064
Phone (386) 339-1060
Specialties & licenses
| Specialty (taxonomy) | Code | License | State | Primary |
|---|---|---|---|---|
| Pediatrics Physician |
208000000X | FL | ||
| Pediatrics Physician |
208000000X | ME87551 | FL | |
| Rural Health Clinic/Center | 261QR1300X | ME87551 | FL | Yes |
Addresses
Primary practice location
North Florida Pediatrics, PA
1117 NW Hwy 41 Ste B
Jasper, FL 32052
Mailing address
1859 SW Newland Way
Lake City, FL 32025
Phone (386) 758-0003
Other identifiers
| Identifier | Type | State | Issuer |
|---|---|---|---|
| 001534800 | Medicaid | FL |
Other providers in Jasper, FL
- Meridian Behavioral Healthcare, Inc.
- David Cameron Miller
- Kylil Abraham Morales
- Michael David Newman
- W. Benjamin Norris Jr.
- North Florida Pediatrics, PA
- North Florida Pediatrics, PA.
- One Stop Staffing, Training, & Consulting LLC
- Tyler Owen
- Yong Park
All providers in Jasper, FL · Rural Health Clinic/Center in Florida
Sources for this page
- NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Record last updated by the provider on Sep 8, 2021. Information in NPPES is self-reported and not verified by CMS.
- NUCC Health Care Provider Taxonomy: specialty names.
- Medicare Fee-For-Service Public Provider Enrollment (CMS/PECOS): enrollments, PAC IDs and benefit reassignments.
- CMS facility enrollments, All Owners and change-of-ownership files: CCNs, owners and managing parties.
- Provider of Services files (CMS): certification status, beds and related CCNs.
- National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.