NPIMap

Organization Active NPI

North Florida Pediatrics PA

  • Rural Health Clinic/Center
  • Starke, FL
National Provider Identifier
1548758428
Registry record updated Sep 8, 2021
On this page

Key facts

NPPES NPI Registry
Primary specialty
Rural Health Clinic/CenterTaxonomy code 261QR1300X
Legal business name
NORTH FLORIDA PEDIATRICS PA
Practice address
417 East Call Street
Starke, FL 32091
Phone
(904) 368-0368
Fax
(904) 317-4949
NPI assigned
Apr 26, 2018
Last updated
Sep 8, 2021By the provider in NPPES
Organization subpart
Yes
Parent organization
NORTH FLORIDA PEDIATRICS PAAs reported in NPPES

NPPES NPI Registry

Updated by the provider on Sep 8, 2021

Registry information is reported by the provider to CMS and is not verified. About this source

Authorized official

Name
Samuel SantelicesNPI 1669476552
Title
President/Ceo
Phone
(386) 758-0003

Authorized official NPPES reports the official by name only. The link goes to the one practitioner connected to this organization with that name.

Specialties & licenses 2

Specialty (taxonomy)CodeLicenseStatePrimary
Pediatrics Physician 208000000X NU
Rural Health Clinic/Center 261QR1300X NU Primary

Addresses

Primary practice location

417 East Call Street
Starke, FL 32091

Mailing address

1859 S.W. Newland Way
Lake City, FL 32025
Phone (386) 758-0003

Other identifiers 1

IdentifierTypeStateIssuer
101707400MedicaidFL

Medicare participation

Medicare enrollment files
Medicare fee-for-service enrollment
Enrolled in FL

Enrollment records 1

Enrollment IDStateProvider typePAC IDDetails
O20180724000602 FL Part A Provider - Rural Health Clinic 8729997929 Practice locations: Starke, FL

NPI to CCN mapping 1

The Medicare certification numbers (CCNs) connected to NPI 1548758428. Details of each certification follow.

Rural health clinic certification: CCN 683828

Legal name
NORTH FLORIDA PEDIATRICS, PA
Certification status
Active
Provider type (POS)
Rural health clinic
Participating since
Oct 12, 2018
Last certification
Sep 9, 2025
Ownership / control type
Non-profit – church related
Organization structure
CorporationProprietary
Incorporated
Nov 29, 1995 in FL
Enrollment address
417 E Call St
Starke, FL 32091-3401

Other NPIs with the same Medicare PAC ID 5

NPIs whose Medicare enrollments share a PECOS associate control ID (the same enrolled entity).

National Provider Directory

National Provider Directory
Tax ID family
North Florida Pediatrics PA18 organizations share this tax ID, including this one
Part of
North Florida Pediatrics PA

Other organizations with this tax ID 17

Organizations that report the same tax identification number in the National Provider Directory.

View all 17

Member organizations 2

Organizations listed as members of this organization in the National Provider Directory.

Locations

417 E Call St
Fl Pediatrics
Starke, FL 32091

Ownership & related parties

All disclosed owners & managing parties 1

As disclosed on the Medicare enrollment (CMS All Owners files). Individuals include officers, directors and managing employees, who may not hold ownership.

NameRoleSinceShare
Samuel Santelices Individual 5% Or Greater Direct Ownership Interest Jan 1, 2010 100%
Corporate OfficerPresident/Ceo/Medical Director Jan 1, 2010 100%
W-2 Managing EmployeePresident/Ceo/Medical Director Jan 1, 2010 100%

Owners & managing parties with NPI records 1

Owners and managing parties disclosed on this facility’s Medicare enrollment that are themselves Medicare-enrolled.

All facility ownership & control disclosures 2

Facilities whose Medicare enrollment lists this provider’s PECOS associate ID as an owner or managing party.

FacilityTypeRoleSince
Acute Care Pediatrics,PAPalatka, FL, CCN 108985 Rural health clinic 5% Or Greater Direct Ownership Interest May 1, 2024
Acute Care Pediatrics of Palm Coast PAPalm Coast, FL, CCN 108997 Rural health clinic 5% Or Greater Direct Ownership Interest (100%) May 1, 2024

Owned or controlled facilities with NPI records 2

Facilities whose Medicare enrollment lists this provider as an owner, officer, director or managing party.

Practitioners & affiliated clinicians

Practitioners 4

Individual providers connected to this organization through Medicare benefit reassignment, Care Compare group membership or National Provider Directory roles, and the practitioner matching its NPPES authorized official.

NPI Registry JSON

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1524700800000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1631059200000",
    "number": "1548758428",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "1859 S.W. NEWLAND WAY",
            "city": "LAKE CITY",
            "state": "FL",
            "postal_code": "32025",
            "telephone_number": "386-758-0003",
            "fax_number": "386-755-4432"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "417 EAST CALL STREET",
            "city": "STARKE",
            "state": "FL",
            "postal_code": "32091",
            "telephone_number": "904-368-0368",
            "fax_number": "904-317-4949"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "NORTH FLORIDA PEDIATRICS PA",
        "organizational_subpart": "YES",
        "parent_organization_legal_business_name": "NORTH FLORIDA PEDIATRICS PA",
        "enumeration_date": "2018-04-26",
        "last_updated": "2021-09-08",
        "certification_date": "2021-09-08",
        "status": "A",
        "authorized_official_last_name": "SANTELICES",
        "authorized_official_first_name": "SAMUEL",
        "authorized_official_title_or_position": "PRESIDENT/CEO",
        "authorized_official_telephone_number": "386-758-0003"
    },
    "taxonomies": [
        {
            "code": "208000000X",
            "taxonomy_group": "",
            "desc": "Pediatrics",
            "state": "NU",
            "license": null,
            "primary": false
        },
        {
            "code": "261QR1300X",
            "taxonomy_group": "",
            "desc": "Clinic/Center, Rural Health",
            "state": "NU",
            "license": null,
            "primary": true
        }
    ],
    "identifiers": [
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "101707400",
            "state": "FL"
        }
    ],
    "endpoints": [],
    "other_names": []
}

Other providers in Starke, FL

Sources for this page

Verify at the official NPI Registry.