Basic Information
| Provider Information | |||||||||
| NPI: | 1124491816 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | SANFORD PEDIATRIC ASSOCIATES PA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 775 HARLEY STRICKLAND BLVD | ||||||||
| Address2: | SUITE 101 | ||||||||
| City: | ORANGE CITY | ||||||||
| State: | FL | ||||||||
| PostalCode: | 327637963 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3868510644 | ||||||||
| FaxNumber: | 3868510664 | ||||||||
| Practice Location | |||||||||
| Address1: | 775 HARLEY STRICKLAND BLVD | ||||||||
| Address2: | SUITE 101 | ||||||||
| City: | ORANGE CITY | ||||||||
| State: | FL | ||||||||
| PostalCode: | 327637963 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3868510644 | ||||||||
| FaxNumber: | 3868510664 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/04/2015 | ||||||||
| LastUpdateDate: | 11/04/2015 | ||||||||
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| AuthorizedOfficialLastName: | TERWILLEGER | ||||||||
| AuthorizedOfficialFirstName: | JOHN | ||||||||
| AuthorizedOfficialMiddleName: | EDWARD | ||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 3868510644 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | DR. | ||||||||
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| AuthorizedOfficialCredential: | M.D. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2080A0000X | ME0045959 | FL | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Pediatrics | Adolescent Medicine |
ID Information
| ID | Type | State | Issuer | Description | 044243700 | 05 | FL | MEDICAID |