Basic Information
| Provider Information | |||||||||
| NPI: | 1629286299 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | ST. AUGUSTINE PEDIATRIC ASSOCIATES, PA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1301 PLANTATION ISLAND DR S | ||||||||
| Address2: | SUITE 106B | ||||||||
| City: | ST AUGUSTINE | ||||||||
| State: | FL | ||||||||
| PostalCode: | 320803108 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9044618906 | ||||||||
| FaxNumber: | 9044617575 | ||||||||
| Practice Location | |||||||||
| Address1: | 1301 PLANTATION ISLAND DR S | ||||||||
| Address2: | SUITE 106B | ||||||||
| City: | ST AUGUSTINE | ||||||||
| State: | FL | ||||||||
| PostalCode: | 320803108 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9044618906 | ||||||||
| FaxNumber: | 9044617575 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/18/2007 | ||||||||
| LastUpdateDate: | 08/17/2015 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | 11/22/2011 | ||||||||
| NPIReactivationDate: | 08/17/2015 | ||||||||
| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | SOBERANO | ||||||||
| AuthorizedOfficialFirstName: | MICHAEL | ||||||||
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| AuthorizedOfficialTitleorPosition: | OWNER | ||||||||
| AuthorizedOfficialTelephone: | 9048245437 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | DR. | ||||||||
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| AuthorizedOfficialCredential: | MD | ||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208000000X | ME78696 | FL | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Pediatrics |
No ID Information.