Healthcare Provider Details

I. General information

NPI: 1689189540
Provider Name (Legal Business Name): BAPTIST PRIMARY CARE INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/13/2017
Last Update Date: 11/22/2023
Certification Date: 11/22/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1370 13TH AVE S STE 216
JACKSONVILLE BEACH FL
32250-3206
US

IV. Provider business mailing address

PO BOX 45443
SALT LAKE CITY UT
84145-0443
US

V. Phone/Fax

Practice location:
  • Phone: 904-247-7778
  • Fax: 904-241-9673
Mailing address:
  • Phone: 904-202-1032
  • Fax: 904-376-4107

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number
License Number StateFL
# 2
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number
License Number StateFL

VIII. Authorized Official

Name: MARSHA DONALDSON
Title or Position: VICE PRESIDENT
Credential:
Phone: 904-376-3703