Healthcare Provider Details

I. General information

NPI: 1083019772
Provider Name (Legal Business Name): BAPTIST NEUROLOGY INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/24/2014
Last Update Date: 04/15/2026
Certification Date: 04/15/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2310 VILLAGE SQUARE PKWY STE 202
FLEMING ISLAND FL
32003-6409
US

IV. Provider business mailing address

PO BOX 746649
ATLANTA GA
30374-6649
US

V. Phone/Fax

Practice location:
  • Phone: 904-516-1880
  • Fax: 904-516-1885
Mailing address:
  • Phone: 904-202-2092
  • Fax: 904-376-4075

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2084E0001X
TaxonomyEpilepsy Physician
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code2084N0400X
TaxonomyNeurology Physician
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number
License Number State

VIII. Authorized Official

Name: TYRONE MCCLOUD
Title or Position: EXECUTIVE DIRECTOR
Credential:
Phone: 904-202-5367