Healthcare Provider Details

I. General information

NPI: 1851965164
Provider Name (Legal Business Name): BAPTIST SPECIALTY PHYSICIANS INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/20/2021
Last Update Date: 05/20/2021
Certification Date: 05/20/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3650 NW DEVANE ST
LAKE CITY FL
32055-8730
US

IV. Provider business mailing address

PO BOX 44047
JACKSONVILLE FL
32231-4047
US

V. Phone/Fax

Practice location:
  • Phone: 904-202-8550
  • Fax: 904-393-7808
Mailing address:
  • Phone: 904-376-4083
  • Fax: 904-391-5075

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207RA0002X
TaxonomyAdult Congenital Heart Disease Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code207RC0000X
TaxonomyCardiovascular Disease Physician
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code2080P0202X
TaxonomyPediatric Cardiology Physician
License Number
License Number State

VIII. Authorized Official

Name: THABATA FORD
Title or Position: VICE PRESIDENT
Credential:
Phone: 904-391-5578