Healthcare Provider Details

I. General information

NPI: 1982836169
Provider Name (Legal Business Name): BAPTIST NEUROLOGY INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/20/2009
Last Update Date: 11/22/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

841 PRUDENTIAL DR 10TH FLOOR
JACKSONVILLE FL
32207-8329
US

IV. Provider business mailing address

841 PRUDENTIAL DR 10TH FLOOR
JACKSONVILLE FL
32207-8329
US

V. Phone/Fax

Practice location:
  • Phone: 904-398-5404
  • Fax: 904-391-5545
Mailing address:
  • Phone: 904-398-5404
  • Fax: 904-391-5545

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2084N0400X
TaxonomyNeurology Physician
License Number
License Number State

VIII. Authorized Official

Name: EARL B MALLY
Title or Position: SENIOR VICE PRESIDENT
Credential:
Phone: 904-376-4275