Healthcare Provider Details

I. General information

NPI: 1609391929
Provider Name (Legal Business Name): BAPTIST PHYSICIAN GROUP LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/08/2017
Last Update Date: 08/08/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8880 NAVARRE PKWY STE 206
NAVARRE FL
32566-3614
US

IV. Provider business mailing address

PO BOX 30532
PENSACOLA FL
32503-1532
US

V. Phone/Fax

Practice location:
  • Phone: 850-916-8697
  • Fax: 860-916-8666
Mailing address:
  • Phone: 850-478-1312
  • Fax: 850-474-9060

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207QS0010X
TaxonomySports Medicine (Family Medicine) Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code2081S0010X
TaxonomySports Medicine (Physical Medicine & Rehabilitation) Physician
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number
License Number State
# 4
Primary TaxonomyY
Taxonomy Code207X00000X
TaxonomyOrthopaedic Surgery Physician
License Number
License Number State

VIII. Authorized Official

Name: BRYON SCOTT RAYNES
Title or Position: PRESIDENT
Credential:
Phone: 850-469-2319