North Florida Pediatrics, PA.
Organization Active NPI Rural Health Clinic/Center · Lake City, FL
NPI 1376548602 · NPPES record last updated Sep 8, 2021
Key facts
- NPI
- 1376548602
- 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 .
1859 SW Newland Way
Lake City, FL 32025 - Phone
- (386) 758-0003
- Fax
- (386) 755-4432
- NPI assigned
- Jun 14, 2005
- Organization subpart
- Yes
- Parent organization (as reported)
- NORTH FLORIDA PEDIATRICS, P.A
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 with the same Medicare PAC ID 5
Corporate family (same tax ID) 16
Practitioners 15
-
Alonso Avendano, PA-C
-
Jessica Ann Brown, FNP-BC, APRN
-
Maria Anne Harmon, ARNP
-
Patricia Jamo-Place, ARNP
-
Leidys Lopez, NP-C
-
Giraldo Olivera, APRN
-
Sherry Ann Singer, FNP-C
-
Maria D. Smith, M.D.
-
Dwight Peter Lim Tiu, M.D.
-
Jasmine Loving Dawson, FNP-C
-
Andrew G. Neal, RN, MS(N), FNP-BC
Laboratory certificates & supplier records
CLIA laboratory certificates
| CLIA number | Laboratory | Certificate | Expires |
|---|---|---|---|
| 10D0911918 | North Florida Pediatrics | Certificate of waiver | Oct 28, 2027 |
Medicare participation
- Medicare fee-for-service enrollment
- Enrolled in FL
Rural health clinic certification: CCN 103931
- Legal name
- NORTH FLORIDA PEDIATRICS, PA
- Certification status
- Active
- Provider type (POS)
- Rural health clinic
- Participating since
- May 9, 1996
- Last certification
- Nov 30, 2023
- Ownership / control type
- 1B
- Organization structure
- Corporation · Proprietary
- Incorporated
- Nov 29, 1995 in FL
- Enrollment address
- 1859 SW Newland Way
Lake City, FL 32025-6966
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 |
|---|---|---|---|---|
| O20100301000379 | FL | Part a Provider - Rural Health Clinic | 8729997929 | Practice locations: Lake City, FL |
National Provider Directory
- Tax ID family
- North Florida Pediatrics PA
- Part of
- North Florida Pediatrics PA
Locations
9770 Old Baymeadows Rd
Jacksonville, FL 32256
1859 SW Newland Way
Fl Pediatrics
Lake City, FL 32025
Phone (386) 758-0003
1301 Reid St
Palatka, FL 32177
Phone (386) 325-1025
397 Palm Coast Pkwy SW
Unit 303
Palm Coast, FL 32137
Phone (386) 447-7337
417 E Call St
Starke, FL 32091
Phone (904) 368-0368
Specialties & licenses
| Specialty (taxonomy) | Code | License | State | Primary |
|---|---|---|---|---|
| Pediatrics Physician |
208000000X | ME87551 | FL | |
| Pediatric Adolescent Medicine Physician |
2080A0000X | ME87551 | FL | |
| Rural Health Clinic/Center | 261QR1300X | ME87551 | FL | Yes |
Addresses
Primary practice location
North Florida Pediatrics PA .
1859 SW Newland Way
Lake City, FL 32025
Mailing address
1859 SW Newland Way
Lake City, FL 32025-6966
Phone (386) 758-0003
Other identifiers
| Identifier | Type | State | Issuer |
|---|---|---|---|
| 001532500 | Medicaid | FL |
Other providers in Lake City, FL
- North Florida Home Health Solutions Inc
- North Florida Medical Sales & Rentals Inc.
- North Florida Mental Health and Wellness Center
- North Florida Neurodiagnostics, LLC
- North Florida Pediatrics, PA
- North Florida Pharmacy, Inc.
- North Florida Pharmacy, Inc.
- North Florida Pharmacy, Inc.
- North Florida Primary Care PLLC
- North Florida Radiation Oncology
All providers in Lake City, 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.
- Medicare Care Compare provider data (CMS): clinician profile, group practices, facility affiliations, MIPS scores and star ratings.
- National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.