Healthcare Provider Details

I. General information

NPI: 1174512701
Provider Name (Legal Business Name): BAYMEADOWS PRIMARY CARE, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/17/2005
Last Update Date: 03/14/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10058 BAYMEADOWS RD
JACKSONVILLE FL
32256-7177
US

IV. Provider business mailing address

10058 BAYMEADOWS RD
JACKSONVILLE FL
32256-7177
US

V. Phone/Fax

Practice location:
  • Phone: 904-636-5400
  • Fax: 904-928-0654
Mailing address:
  • Phone: 904-636-5400
  • Fax: 904-928-0654

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberME71382
License Number StateFL
# 2
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License NumberME81517
License Number StateFL

VIII. Authorized Official

Name: MR. S. AWAIS IMAM
Title or Position: PRACTICE ADMINISTRATOR/ CFO
Credential:
Phone: 904-636-5400