Healthcare Provider Details

I. General information

NPI: 1619140662
Provider Name (Legal Business Name): PALMETTO BEHAVIORAL MEDICINE INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/10/2008
Last Update Date: 10/01/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3002 SE 1ST AVE SUITE 100
OCALA FL
34471-0407
US

IV. Provider business mailing address

3002 SE 1ST AVE SUITE 100
OCALA FL
34471-0407
US

V. Phone/Fax

Practice location:
  • Phone: 352-368-2448
  • Fax:
Mailing address:
  • Phone: 352-368-2448
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License NumberME100494
License Number StateFL
# 2
Primary TaxonomyN
Taxonomy Code2084P0805X
TaxonomyGeriatric Psychiatry Physician
License NumberME100494
License Number StateFL

VIII. Authorized Official

Name: DR. MICAH DENNIS BAXLEY
Title or Position: PRESIDENT
Credential: MD
Phone: 352-368-2448