Healthcare Provider Details

I. General information

NPI: 1306107099
Provider Name (Legal Business Name): BAPTIST AGEWELL PHYSICIANS INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/30/2012
Last Update Date: 07/29/2026
Certification Date: 07/29/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3563 PHILIPS HWY STE 101
JACKSONVILLE FL
32207-5627
US

IV. Provider business mailing address

PO BOX 746636
ATLANTA GA
30374-6636
US

V. Phone/Fax

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

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number
License Number StateNULL
# 2
Primary TaxonomyN
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number
License Number StateNULL
# 3
Primary TaxonomyN
Taxonomy Code104100000X
TaxonomySocial Worker
License Number
License Number StateNULL
# 4
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number
License Number StateNULL
# 5
Primary TaxonomyN
Taxonomy Code207QG0300X
TaxonomyGeriatric Medicine (Family Medicine) Physician
License Number
License Number StateNULL
# 6
Primary TaxonomyN
Taxonomy Code207RG0300X
TaxonomyGeriatric Medicine (Internal Medicine) Physician
License Number
License Number StateNULL

VIII. Authorized Official

Name: ELIZABETH TIBBS
Title or Position: VICE PRESIDENT
Credential:
Phone: 904-202-3283