Basic Information
| Provider Information | |||||||||
| NPI: | 1396805115 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | PEDIATRIC AND INTERNAL MEDICINE SPECIALISTS LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 2066 | ||||||||
| Address2: | |||||||||
| City: | LECANTO | ||||||||
| State: | FL | ||||||||
| PostalCode: | 344602066 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3525276888 | ||||||||
| FaxNumber: | 3525278818 | ||||||||
| Practice Location | |||||||||
| Address1: | 1990 N PROSPECT AVE | ||||||||
| Address2: | |||||||||
| City: | LECANTO | ||||||||
| State: | FL | ||||||||
| PostalCode: | 344619792 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3525276888 | ||||||||
| FaxNumber: | 3525278818 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/11/2006 | ||||||||
| LastUpdateDate: | 03/17/2018 | ||||||||
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| AuthorizedOfficialLastName: | ST. MARTIN | ||||||||
| AuthorizedOfficialFirstName: | DACELIN | ||||||||
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| AuthorizedOfficialTitleorPosition: | MEDICAL DIRECTOR/OWNER | ||||||||
| AuthorizedOfficialTelephone: | 3525276888 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | DR. | ||||||||
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| AuthorizedOfficialCredential: | MD | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine | 208000000X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Pediatrics | 261Q00000X | 10D1050573 | FL | N | Ambulatory Health Care Facilities | Clinic/Center | 261QS1200X | N | Ambulatory Health Care Facilities | Clinic/Center | Sleep Disorder Diagnostic | 207Q00000X | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Family Medicine |
No ID Information.