Provider Demographics
NPI:1447461421
Name:ST. AUGUSTINE PEDIATRIC ASSOCIATES, PA
Entity type:Organization
Organization Name:ST. AUGUSTINE PEDIATRIC ASSOCIATES, PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:
Authorized Official - Last Name:SOBERANO
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:904-824-5437
Mailing Address - Street 1:493 PROSPERITY LAKE DR
Mailing Address - Street 2:
Mailing Address - City:ST AUGUSTINE
Mailing Address - State:FL
Mailing Address - Zip Code:32092-5045
Mailing Address - Country:US
Mailing Address - Phone:904-824-5437
Mailing Address - Fax:904-824-7575
Practice Address - Street 1:493 PROSPERITY LAKE DR
Practice Address - Street 2:
Practice Address - City:ST AUGUSTINE
Practice Address - State:FL
Practice Address - Zip Code:32092-5045
Practice Address - Country:US
Practice Address - Phone:904-824-5437
Practice Address - Fax:904-824-7575
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:ST. AUGUSTINE PEDIATRICS
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2007-05-24
Last Update Date:2015-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME78696208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL257545101Medicaid