Provider Demographics
NPI:1053598292
Name:ANCIENT CITY PEDIATRICS
Entity type:Organization
Organization Name:ANCIENT CITY PEDIATRICS
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:ADRIENNE
Authorized Official - Middle Name:
Authorized Official - Last Name:MCCOY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:904-461-1560
Mailing Address - Street 1:1301 PLANTATION ISLAND DR S STE 104
Mailing Address - Street 2:
Mailing Address - City:SAINT AUGUSTINE
Mailing Address - State:FL
Mailing Address - Zip Code:32080-3108
Mailing Address - Country:US
Mailing Address - Phone:904-461-1560
Mailing Address - Fax:904-461-4304
Practice Address - Street 1:1301 PLANTATION ISLAND DR S STE 104
Practice Address - Street 2:
Practice Address - City:SAINT AUGUSTINE
Practice Address - State:FL
Practice Address - Zip Code:32080-3108
Practice Address - Country:US
Practice Address - Phone:904-461-1560
Practice Address - Fax:904-461-4304
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-01-30
Last Update Date:2024-10-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Single Specialty