| Entity Name: | ST AUGUSTINE PEDIATRIC ASSOCIATES, PA |
| Jurisdiction: | FLORIDA |
| Filing Type: | Domestic Profit |
| Status: | Inactive |
| Date Filed: | 20 Feb 2003 (22 years ago) |
| Date of dissolution: | 27 Sep 2024 (4 months ago) |
| Last Event: | ADMIN DISSOLUTION FOR ANNUAL REPORT |
| Event Date Filed: | 27 Sep 2024 (4 months ago) |
| Document Number: | P03000020979 |
| FEI/EIN Number | 421577151 |
| Address: | 12877 Cannington Cove Terrace, Jacksonville, FL, 32258, US |
| Mail Address: | 12877 Cannington Cove Terrace, Jacksonville, FL, 32258, US |
| ZIP code: | 32258 |
| County: | Duval |
| Place of Formation: | FLORIDA |
| NPI | Enumeration Date | Last Update Date | Mailing Address | Practice Location Address | |||||||||||||||||||||||||
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| 1447461421 | 2007-05-24 | 2015-07-21 | 493 PROSPERITY LAKE DR, ST AUGUSTINE, FL, 320925045, US | 493 PROSPERITY LAKE DR, ST AUGUSTINE, FL, 320925045, US | |||||||||||||||||||||||||
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| Phone | +1 904-824-5437 |
| Fax | 9048247575 |
Authorized person
| Name | MICHAEL SOBERANO |
| Role | OWNER |
| Phone | 9048245437 |
Taxonomy
| Taxonomy Code | 208000000X - Pediatrics Physician |
| License Number | ME78696 |
| State | FL |
| Is Primary | Yes |
Other Provider Identifiers
| Issuer | MEDICAID |
| Number | 257545101 |
| State | FL |
| Name | Role | Address |
|---|---|---|
| SOBERANO MICHAEL M | Agent | 12877 Cannington Cove Terrace, Jacksonville, FL, 32258 |
| Name | Role | Address |
|---|---|---|
| SOBERANO MICHAEL M | President | 12877 Cannington Cove Terrace, Jacksonville, FL, 32258 |
| Name | Role | Address |
|---|---|---|
| Soberano Gregory A | Auth | 12877 Cannington Cove Terrace, Jacksonville, FL, 32258 |
| Name | Role | Address |
|---|---|---|
| Soberano GREGORY A | Vice President | 12877 Cannington Cove Terrace, Jacksonville, FL, 32258 |
| Event Type | Filed Date | Value | Description |
|---|---|---|---|
| ADMIN DISSOLUTION FOR ANNUAL REPORT | 2024-09-27 | No data | No data |
| CHANGE OF PRINCIPAL ADDRESS | 2023-04-25 | 12877 Cannington Cove Terrace, Jacksonville, FL 32258 | No data |
| CHANGE OF MAILING ADDRESS | 2023-04-25 | 12877 Cannington Cove Terrace, Jacksonville, FL 32258 | No data |
| REGISTERED AGENT ADDRESS CHANGED | 2023-04-25 | 12877 Cannington Cove Terrace, Jacksonville, FL 32258 | No data |
| AMENDMENT | 2020-04-16 | No data | No data |
| REGISTERED AGENT NAME CHANGED | 2018-03-10 | SOBERANO, MICHAEL M | No data |
| Name | Date |
|---|---|
| ANNUAL REPORT | 2023-04-25 |
| ANNUAL REPORT | 2022-03-09 |
| ANNUAL REPORT | 2021-04-12 |
| ANNUAL REPORT | 2020-05-11 |
| Amendment | 2020-04-16 |
| ANNUAL REPORT | 2019-04-01 |
| ANNUAL REPORT | 2018-03-10 |
| ANNUAL REPORT | 2017-03-26 |
| ANNUAL REPORT | 2016-04-13 |
| ANNUAL REPORT | 2015-02-11 |
Date of last update: 03 Feb 2025
Sources: Florida Department of State
