Healthcare Provider Details

I. General information

NPI: 1124788146
Provider Name (Legal Business Name): BAPTIST AGEWELL PHYSICIANS INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/20/2021
Last Update Date: 03/03/2026
Certification Date: 03/03/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

700 3RD ST STE 102
NEPTUNE BEACH FL
32266-5082
US

IV. Provider business mailing address

PO BOX 746636
ATLANTA GA
30374-6636
US

V. Phone/Fax

Practice location:
  • Phone: 904-202-4243
  • Fax: 904-202-4639
Mailing address:
  • Phone: 904-202-2092
  • Fax: 904-376-4075

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207QG0300X
TaxonomyGeriatric Medicine (Family Medicine) Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code207RG0300X
TaxonomyGeriatric Medicine (Internal Medicine) Physician
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code225X00000X
TaxonomyOccupational Therapist
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code235Z00000X
TaxonomySpeech-Language Pathologist
License Number
License Number State

VIII. Authorized Official

Name: ELIZABETH TIBBS
Title or Position: EXECUTIVE DIRECTOR
Credential:
Phone: 904-202-3283